Inspection on 17/05/07 for St Martins Residential Home

This inspection was carried out on 17th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Martins Residential Home 26/08/09

St Martins Residential Home 12/08/08

St Martins Residential Home 15/08/06

St Martins Residential Home 27/02/06

St Martins Residential Home 05/10/05

St Martins Residential Home 24/01/05

St Martins Residential Home 28/09/04

St Martins Residential Home 05/02/04

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

CARE HOME ADULTS 18-65 St Martins Residential Home 63 Martins Lane Wallasey Wirral CH44 1BG Lead Inspector Peter Cresswell Key Unannounced Inspection 17th May 2007 09:30 St Martins Residential Home DS0000018941.V335114.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.V335114.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.V335114.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.V335114.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 15th August 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 three 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, only a short walk from St Martins. The Registered Person owns another similar home nearby. St Martins Residential Home DS0000018941.V335114.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. The Registered Manager was on an extended absence and the visit was dealt with by his line manager, who is the Registered Manager of the owner’s other nearby home. The inspector also spoke to a majority of the residents - mainly in a group in the conservatory - the owner and three members of staff. He toured the home, examined medication administration and a range of documents, including residents’ files, and fire safety records. No pre inspection questionnaire was returned before the visit, owing to the absence of the Registered Manager. What the service does well: What has improved since the last inspection? What they could do better: The prolonged absence of the Registered Manager has hampered progress in meeting some of the matters arising from the last two inspections. Some maintenance and refurbishment work needs to be carried out and the smoking lounge/conservatory still does not have an extractor fan, leading to a possible health hazard, especially for non smokers. Accessible care plans are not yet in place for everyone, though the process of introducing a new, computer based system of care planning documentation was under way. Some essential documents, such as the complaints file and the accident reports file, could not be located. The Communications Book is still being used to convey confidential information despite this issue being raised at St Martins Residential Home DS0000018941.V335114.R01.S.doc Version 5.2 Page 6 two inspections. The home does not yet have a quality assurance system. Although there is an NVQ training programme, other training has fallen off and needs to be reinstated as soon as possible. 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 Residential Home DS0000018941.V335114.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.V335114.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): 1, 2 and 5. Quality in this outcome area is adequate. Current and prospective residents 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 any new residents who are admitted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service user guide still refers to the now defunct ‘National Care Standards Commission’ which was replaced two years ago by the Commission for Social Care Inspection. The guide is a document which is required by the Care Homes Regulations and should contain useful information for present and prospective residents. It should be reviewed regularly to make sure that it provides accurate information. Reference to an organisation which was abolished two years ago indicates that it has not been reviewed for some time. There have been no new residents at St Martins for some time so it was not possible to assess the admission and assessment procedures. Assessment forms are in place. Fees at St Martins are £346.92 a week. St Martins Residential Home DS0000018941.V335114.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 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In the absence of the Registered Manager (see the final section of this report) the group manager has begun the process of drawing up care plans on the computerised ‘Care Management System’ (CMS). This is a comprehensive system which is used in St Martins’ sister home. It can contain all of the relevant information on residents, including easily updated care plans. Due to the circumstances, progress is rather slow, but those care plans which are on the system are clear and easy to use and update. All of the files seen contain a great deal of information about the resident, but it is often not in a format which is readily useable by staff who are caring for the resident. Daily reports are made in a large folder which contains some basic details of the residents. It would be more helpful if the file contained summaries of the care plans so that staff making the reports have instant access to a reminder of the essence of the care plan. The communications (staff handover) book still contains St Martins Residential Home DS0000018941.V335114.R01.S.doc Version 5.2 Page 10 inappropriate entries, such as detailed references to individuals’ continence. Where confidential or sensitive information needs to be passed on to the next shift the communications book should be used, in effect, as a ‘signpost’ to the resident’s personal file, where the relevant information should be kept. This has been pointed out in previous reports and should be made an issue in a staff meeting or training set. Most of the residents go out of the home on their own and with other residents and friends; They are encouraged to take as many decisions as possible about their daily routines and their lives. 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.V335114.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, 14, 15, 16, 17. Quality in this outcome area is good. Residents are able to take part in activities of their choice and the 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Several residents talked to the inspector about the day centres and drop in centres they attend, where they take part in a range of activities and training. Several residents said that they go on trips out with one of the centres and they felt that similar trips from the home would be a good idea. The owner said that some sort of transport might be bought for the home at some point in the future. Residents take part in various other activities, such as lunch clubs, and the staff help them with some activities. One support worker was about to introduce beauty therapy sessions for the residents. Most of the residents make their own arrangements, going out to shops, cafes and other local facilities and using public transport – all of those spoken to have a bus pass. One of the residents has a cat, which sleeps in her room. The post of part St Martins Residential Home DS0000018941.V335114.R01.S.doc Version 5.2 Page 12 time Activities Organiser has not yet been filled but the group manager said that it is planned to do so shortly. Some of the residents do 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. Residents spoke highly of the food in the home, especially when the cook is on duty. The cook said that she will prepare individual meals to suit the tastes of particular residents if they ask. During the site visit staff approached residents as they got up and asked them what they wanted for breakfast. The evening meal is still served at the rather early hour of 4.30, though none of the residents complained about this. The timing of the evening meal might be a suitable focus for quality assurance. Snacks such as biscuits and toast are freely available throughout the day. At the moment there are no residents with particular cultural needs in respect of food. St Martins Residential Home DS0000018941.V335114.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Few of the current residents at St Martins need physical personal support. The group manager is still working on the introduction of a keyworker system, which would help the development of care plans and activities. Residents receive all of the community and specialist medical support that they need and several have the support of a Community Psychiatric Nurse. Correspondence and assessments from psychiatrists and CPNs were on the files seen during this inspection. The inspector checked in detail the medication for three residents. 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. In one case the number of prescribed Paracetamol carried over from the previous month had not been recorded on the Medication Administration Record (MAR) sheet so it was difficult to account for the exact number used. There were no guidelines on the circumstances in which one medication to be taken ‘as required’ (PRN) was to be given. A St Martins Residential Home DS0000018941.V335114.R01.S.doc Version 5.2 Page 14 suitable special cabinet is available for Controlled Drugs should any be prescribed. The home does not keep homely remedies. St Martins Residential Home DS0000018941.V335114.R01.S.doc Version 5.2 Page 15 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 adequate. The home has a complaints procedure which residents can use to make their views heard, though records of complaints are still not yet filed adequately. The new draft procedures for disciplinary action should clarify the action the home will take to protect those in its care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been two recent referrals from the home concerning allegations of adult abuse. These were properly referred to the local adult protection scheme via Social Services. In one case there were some issues about whether the allegations had been dealt with appropriately in the first instance and if the home’s internal procedures were sufficiently clear about issues such as suspension without pay. Consequently the owner has obtained some draft procedures from the company’s legal representatives, in the form of an Employee’s Handbook. These are not yet in final form but the owner said that they will be introduced as soon as possible. St Martins has a complaints procedure, though the complaints section in the service user guide still refers to the National Care Standards Commission, which was replaced two years ago by the Commission for Social Care Inspection. However, at the time of the site visit the complaints file was not accessible. This was partly due to the extended absence of the Registered Manager (see final section of this report – Management and Administration) but the home’s filing and administrative systems should be clear and accessible to all relevant staff. St Martins Residential Home DS0000018941.V335114.R01.S.doc Version 5.2 Page 16 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, 25, 26, 27, 28, 29, 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Martin’s is in a residential area of Wallasey near Liscard Village where there are shops, a post office and other local facilities for the community. There is a corner shop a few yards from 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 main entrance is at the lower ground 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. There is one resident who is over 65, but she has a ground floor room and is in any event physically able to cope with stairs. 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 St Martins Residential Home DS0000018941.V335114.R01.S.doc Version 5.2 Page 17 residents smoke. The conservatory still does not have an extractor fan so it is very smoky. It is a pleasant space and is well used by residents who do not smoke, as well as visitors (and inspectors) and should therefore have a means of extracting the smoke. The owner said that an extractor will be fitted when the smoke free regulations are introduced in July 2007. During this unannounced visit 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, though the far end is overgrown. The rockery is designed in an imaginative and distinctive way, using blue wood chips. The communal areas were clean and well maintained. Most residents have single bedrooms. One couple share a room by choice; two others have agreed to share a room and have done so for some time. If and when one of these leaves, the room should only be shared if both people involved make a positive, informed choice to share a room. This is not the same as ‘agreeing’ to share. The bedrooms visited were clean, though the quality of the bedding was mixed and needs to be kept under review. 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. Alarm call points are fitted in each bedroom, though not in the lounges. The inspector did not visit all of the bedrooms on this site visit as some residents were out. The carpet in the corridor on the first floor outside room 8 has been replaced, providing a much improved environment in that area. A number of points require attention: the door frame to room 14 has large gaps around it, which should be filled in; the door to room 4 does not fit properly into its rebate; the vinyl behind the door in room 4 needs to be thoroughly cleaned or replaced; the door to room 5 is very battered and may need to be replaced; the fire door to the old main entrance on the ground floor does not fit into its rebate properly and is therefore ineffective as a fire door. The home has sufficient bathrooms and toilets. 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. The hot water in bathrooms and bedrooms was tested and found to be far too hot. One resident described it as ‘scalding’. The group manager was informed of this before the end of the site visit. The bathrooms and toilets were clean but would benefit from being refurbished. For instance, some of the walls have repainted artex surfaces which are easily damaged, some of the baths and showers need to be resealed or regrouted. The vinyl covering to the two main bathrooms is not securely fixed and has a rumpled appearance. This is not a trip hazard but is certainly unsightly. None of the residents need any specialist equipment at the moment. St Martins Residential Home DS0000018941.V335114.R01.S.doc Version 5.2 Page 18 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): 32, 33, 34, 35, 36. Quality in this outcome area is adequate. St Martins has enough staff to meet the needs of the residents but they need to be properly trained if they are to develop their skills in order to care effectively for the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No new staff had been recruited since the last inspection but some applicants were being interviewed at the time of the site visit. One of the applicants sat with the residents whilst waiting for his interview. The home has procedures in place to ensure that the proper checks are made before new staff are allowed to start work. The group manager is carrying out a programme of supervision and appraisal for all staff. Night staffing has been increased, with two staff on waking night duty, rather than one of them sleeping in. As the sleeping in room (adjacent to the manager’s office) will no longer be needed this will also increase the amount of space for the office and should make it easier to organise the files properly. Four care staff have NVQ2 and a further three are on NVQ2 courses. Two others are studying for a Diploma in Nursing. Therefore St Martin’s therefore does not meet the National Minimum Standard of at least 50 of care staff with NVQ2, though this will be remedied as staff complete their training. Staff have received updates to their moving and St Martins Residential Home DS0000018941.V335114.R01.S.doc Version 5.2 Page 19 handling training, attended a course on Death and Dying and some have attended POVA training with Social Services. There was no evidence of other recent staff training and this is an issue which the group manager recognises needs to be addressed. St Martins Residential Home DS0000018941.V335114.R01.S.doc Version 5.2 Page 20 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, 41, 42. Quality in this outcome area is adequate. The continued absence of the Registered Manager has made it difficult to maintain all of the systems needed to ensure residents’ safety. 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 though some of the recording needs to be kept up to date. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager is not working in the home at the moment. St Martins is being managed temporarily by David Wakefield, the Registered Manager of the owners’ other home. Mr Wakefield is an experienced, qualified person and is the line manager of St Martin’s registered manager. He is in effect the group manager for the owners, Assistwide. This situation needs to be resolved as soon as possible. During the site visit the relationship between staff and St Martins Residential Home DS0000018941.V335114.R01.S.doc Version 5.2 Page 21 residents was relaxed and informal. The inspector spoke to the staff who were on duty and they said that the atmosphere in the home was good. St Martins still does not have a quality assurance system, though the views of residents are gathered at meetings. The owner’s other home has now obtained the Investors In People award but any attempt to secure this for St Martin’s will have to wait until the management position is settled. This would 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 owner visits the home several times a week and prepares reports to meet the requirements of Regulation 26. Accidents are recorded in compliance with the Data Protection Act, but the incident sheets extracted from the accident book could not be located during the site visit. Fire safety certificates were in place and the home’s fire safety systems had been recently checked by a fire safety contractor. Fire drills had been held and recorded but the weekly fire alarm tests had not been recorded for over a month. It is essential that fire safety equipment is tested regularly to protect the safety of residents and staff. It was noticed during the tour of the building that one resident’s door was propped open with personal belongings. If the resident wants to have the door open then a Dorgard or similar device must be fitted so that it closes automatically in the event of an alarm being sounded. . Some fire doors need to be adjusted to ensure that they close automatically into their rebates. The kitchen was clean and well organised. Fridge and freezer temperatures were checked and recorded. The home uses the Food Standards Agency programme Safer Food, Better Business to manage food safety. The records were up to date, though the cook may want to consult the environmental health officer about the amount of detail being recorded. Some parts of the vinyl floor could do with replacing, though this was not required by the environmental health officer when she recently visited the home. Hot water from some of the taps was excessively hot and the thermostat should be checked and adjusted. The Employers Liability Insurance Certificate was displayed in the corridor near to the office and was up to date. St Martins Residential Home DS0000018941.V335114.R01.S.doc Version 5.2 Page 22 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 2 36 3 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 x 2 x 2 2 x St Martins Residential Home DS0000018941.V335114.R01.S.doc Version 5.2 Page 23 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 Timescale for action 01/07/07 2. YA24 23(2)(p) 3. YA26 16(c) 4. YA38 13(4) The Registered Person must prepare a care plan for each resident (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 01/07/07 ensure that suitable ventilation is provided in the home, and must therefore fit an extractor fan or other similar ventilation equipment in the conservatory. The Registered Person must 01/07/07 provide adequate furniture and must therefore: * fill the gaps to the door frame to room 14; * clean or replace the vinyl behind the door in room 4; * repair or replace the door to room 5. The Registered Person must 01/06/07 eliminate risks to the safety of residents and must therefore ensure that: DS0000018941.V335114.R01.S.doc Version 5.2 St Martins Residential Home Page 24 5. YA39 24 6. YA35 18(1) (c) 7. YA41 17(2) * the unsuitable lock to the identified toilet is replaced with a lock that can be opened from the outside in an emergency; * hot water is delivered at a safe temperature; *all fire doors are kept closed unless fitted with an approved hold open device; * the doors to room 4 and the ground floor lobby are repaired so that they fit properly into their rebate; * checks on fire safety equipment are carried out at the specified intervals. The Registered Person must 01/07/07 establish a system for reviewing the quality of care provided at the home; this can be achieved by introducing a quality assurance programme in the home. (Original timescale of 1 November 2006 not met) The Registered Person must 01/08/07 ensure that staff receive appropriate training and must therefore implement and record a full programme of relevant training in addition to the NVQ training in place. The Registered Person must 01/07/07 maintain the following records: * a record of any accident that takes place in the home; * a record of all complaints made and how they were addressed. St Martins Residential Home DS0000018941.V335114.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard YA20 YA27 Good Practice Recommendations 1. 2. Medication records should include details of the circumstances in which medication to be given ‘as required’ (PRN) is to be used. The Registered Person should consider the refurbishment and modernisation of the home’s bathrooms and toilets. St Martins Residential Home DS0000018941.V335114.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Residential Home DS0000018941.V335114.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!