Inspection on 14/01/09 for The Martins

This inspection was carried out on 14th January 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Martins 23/01/07

The Martins 20/01/06

The Martins 17/08/05

The Martins 24/02/05

The Martins 01/09/04

The Martins 26/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: The Martins The Vinefields Bury St Edmunds Suffolk IP33 1YA     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Claire Hutton     Date: 1 4 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: The Martins The Vinefields Bury St Edmunds Suffolk IP33 1YA 01284753467 01284725807 home.bur@mha.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Methodist Homes for the Aged care home 42 Number of places (if applicable): Under 65 Over 65 22 20 dementia old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home 0 0 The Martins was rebuilt in l998, to an extremely high standard. The Martins stands in its own beautifully kept grounds, which are frequently used by residents. The main view from the Home is towards Bury St. Edmunds town centre. Many rooms look on to the historic Abbey Garden ruins and the cathedral, with the River Lark running between the ruins and the home. All community facilities are available in the town centre. The purpose built home is constructed on an incline, therefore has a lower ground floor, which is Lark Close, a ground and first floor that are the main part of the home. The Home has 42 single rooms, each with en-suite WC facilities. Communal areas in the main home comprise a large sitting room and dining room, both of which have entrances onto the veranda and a second lounge on the ground floor. There is an additional sitting room on the first floor equipped with tea making facilities. There is a purpose built hairdressing salon and a small courtyard in the middle of the Home. Care Homes for Older People Page 4 of 29 Brief description of the care home Lark Close is more compact, designed in a simple L shape. It has a kitchen/diner and two lounges for communal space as well as individual bedrooms. It also benefits from a secure sensory garden containing sculptures, seating and scented plants. The home offers accommodation to twenty older people requiring residential care and is registered to support a further twenty-two people with dementia. People with dementia are accommodated in Swallow Close and Lark Close. The fees range between £473.00 and £610.00 per week and do not include the cost of hairdressing, chiropody, newspapers and toiletries. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was a key inspection, which focused on the core standards relating to care homes for Older People. The inspection was unannounced over 2 weekdays, which lasted a total of 12 hours. This report has been written using accumulated evidence gathered before and during the inspection, including information obtained from 3 Have Your Say staff surveys completed by staff, 9 surveys completed by residents and 1 survey completed by a health professional. The Annual Quality Assurance Assessment (AQAA), issued by the Commission for Social Care Inspection (CSCI) was returned completed by the registered manager who has since left the service. This self-assessment gives providers the opportunity to inform the CSCI about their service and how well they are Care Homes for Older People Page 6 of 29 performing. We (CSCI) also assessed the outcomes for the people living at the home against the Key Lines of Regulatory Assessment (KLORA). A tour of the premises was made and a number of records were inspected, relating to people using the service, staff, training, the duty roster, medication and health and safety. Time was spent talking with several people who live in the home and 5 members of staff were interviewed. The newly appointed manager of the home was available during this inspection and fully contributed to the inspection process. The Area Manager was present for part of the second day. What the care home does well: What has improved since the last inspection? What they could do better: We have a made a number of practice recommendations in this report that we believe will improve the experience of people who use this service. We believe that care plans for new residents should be completed in a more timely manner to ensure that key care needs are known immediately by staff to ensure health does not deteriorate. Also risk assessments should be completed in an individualised way that is person centred and not a blanket approach. We found that one individuals care plan contained a risk assessment relating to wandering and this was not individualised but appeared to be a generic risk assessment repeated on other individuals care plans. Care Homes for Older People Page 8 of 29 On the whole practice around medication was very good. However, the fridge used downstairs had on occasion rose to 24 degrees Celsius. This is above the recommended temperature for the storage of medication. When the medication fridge temperatures rise remedial action should be taken to reduce temperatures to ensure medication is stored correctly. And finally, it is good practice to have available the policy, procedure and referral information about safeguarding this will ensure that all have free access to the information, but particularly if it is needed in a hurry to promptly safeguard residents. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can expect to be provided with up to date information about the home, including contracts. Before moving to the home for a trial period people can expect to have an assessment and the home confirm that they can meet those identified needs Evidence: We were given a copy of the statement of purpose and the service users guide. This had been updated with the new managers details. We were able to see that 2 assessments had been completed on new service users. A new service user was being admitted to the home and a pack of information had been compiled which included the statement of purpose, service users guide and a contract including a letter stating that the home could meet the assessed needs of the individual. The contract showed the weekly fees to be paid. The individual resident had commenced the 8 week trial period offered by the home. Care Homes for Older People Page 11 of 29 Care Homes for Older People Page 12 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service can expect to be treated with respect, have their health needs met and have a care plan to help carers support them in their daily life. However the lack of prompt care plans in place for new residents may compromise the quality of care for some. People can also expect to be generally protected by the homes medication administration policy and practice. Evidence: We found that there are good health care pathways in place. The district nurse was visiting three residents at the time of our visit, one of whom was very new to the service. In the handover staff spoke about the GP being called out of hours as staff were concerned about the health of one resident. Staff were also following instruction to obtain urine samples for testing and following medical advice that related to caring for a residents leg. The 9 resident surveys completed stated that residents always received the medical support they needed. One person wrote the staff will deal directly with my doctor if there is an emergency. Otherwise my family are asked to come in and help and advise. Care Homes for Older People Page 13 of 29 Evidence: Two care plan examined showed that assessment relating to continence care and nutrition had been completed. This also included a monthly review and evaluation. There was also evidence that those residents identified at risk were regularly weighed to monitor their weight. One resident wrote in their survey the care and support here it is wonderful. One resident had been living at the home for 5 days. An assessment of needs had been completed and indicated that the individual had a sore on their sacrum, nutritional needs and a history of falling, however the care plan had not been completed to include these key areas of need. We spoke to staff about this individual and they were aware that the individual resident had only one tooth and required a soft diet. We were also told that the individual had arrived with some creams to be applied, but these had been thrown away by staff as they were not dated upon opening and thought to be out the date. This was brought to the attention of the manager who agreed that this matter would be addressed promptly. This individual was due to be seen by the district nurse. However we feel that a care plan of these key needs should have been developed within 24 hours of the resident being admitted to the home to ensure they are adequately cared for. The quality of daily notes made by care staff and the quality of handover from one shift to another was both factual and informative. We examined risk assessment that were in place and found that the manual handling risk assessment were individually detailed and regularly reviewed. However we found that one individuals care plan contained a risk assessment relating to wandering and this was not individualised but appeared to be a generic risk assessment repeated on other individuals care plans. We examined the medication storage and records kept on the ground floor and downstairs. We found that the storage of medication was good and ensured that medication was kept secure and safe. We found currently there were several people who were supported to self medicate. We found that a risk assessment was in place for each individual and was based around the individual circumstances. We examined the records kept by staff and found that the medication administration records were accurately completed and therefore residents received the correct medication at the right time. The home has two medication fridges and the temperature of of these are regularly monitored, however the fridge used downstairs had on occasion rose to 24 degrees Celsius. This is above the recommended temperature for the storage of medication. We also examined the records and storage relating to controlled medication and found everything to be in order. Care Homes for Older People Page 14 of 29 Care Homes for Older People Page 15 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service can expect to be encouraged to maintain contact with the community and their Christan beliefs, offered meaningful pastimes and receive a wellbalanced, appealing and varied diet. Evidence: We found that there was a good level of activities available to residents at The Martins. We obtained a copy of the list of activities that was widely displayed throughout the home for the month of January 2009. This offered frequent access to morning prayers and worship along with specific services with communion. And activities included Scrabble, poetry group, an art group and carpet bowls. There was also frequent visits from a hairdresser and opportunities to see the Treasurer/Banker. On Monday the fifth of January there was a residents group meeting planned. We have the opportunity to speak with the activities organiser. We found her playing indoor golf with a number of residents downstairs in the specialist dementia care unit. She told us that she worked 35 hours a week and split her time between different areas within the home. She explained to us that she had already spent some time upstairs with a group of residents making a large floral display with flowers donated Care Homes for Older People Page 16 of 29 Evidence: from a local supermarket. She explained that the type of activities some residents like to do included bingo, having a manicure and quizzes. However, she also spoke of the specialist activities that she had developed within the dementia care unit that included a session that she had developed that was entitled sonas. This was a session that lasted 1 1/2 hours and consisted of playing a C. D. and encouraged physical exercise that was accompanied by relaxing music and stimulated sensors by using specific sprays to create an aroma and food such as fruit for tasting. She also explained that she used DVDs from the memory store which included famous people, singalongs and dance. The next day the activities organiser was planned to attend a workshop on developing activities for people with dementia. The intention was to develop a more structured programme that would be available to people who lived in the specialist dementia care unit and the home. The activities organiser had obtained a level 2 certificate in the provision of activities and held an NVQ. We spoke with three residents at the Martins and all of them spoke very highly of the activities available to them. One resident spoken with said that the reason she had chosen this care home was that its location was so close to Bury town centre and that she was able to walk from the care home into town. We received nine surveys back from residents all positive about the activities arranged by the home that they could partake in. One resident had written on their survey we have an excellent activities coordinator who can adapt the game to suit e.g. eyesight is poor that Id play carpet bowls and I sometimes win! another resident wrote Im not really bookish, so Id always liked to keep busy with hobbies such as sewing and and art. These are provided by a facilitator. We visited the different dining areas and found the environment were pleasant and dining tables were laid attractively. The menus were displayed and showed each day the main meal on offer. On our first day the main meal was sausage pie, broccoli, courgette, mashed potatoes and gravy there was an alternative of vegetable lasagne. The following week when we visited the main meal was toad in the hole with vegetables. The alternative was risotto. In looking at the menu, food served at the Martins could be described as traditional English food. We have the opportunity to speak with a member of the catering staff. They explained that there had been menu changes based around the preferences of the residents. When we asked about a specific resident requiring a soft diet the member of staff was able to explain how each element of a meal would be pureed separately so that the presentation would be more appealing to the resident. The member of staff also spoke of the quality of food that included home-made soups and the offer of wine and sherry with a meal. We spoke with 2 residents during our visit and both were very positive about the quality of food. One resident said the food here is lovely I eat every morsel. Care Homes for Older People Page 17 of 29 Care Homes for Older People Page 18 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service are listened to and concerns are taken seriously and dealt with appropriately. The current lack of information could compromise matters of safeguarding. Evidence: The Martins had a complaints procedure in place and was part of the service users guide which was given to each resident. In the nine surveys returned from residents all said they were aware of how to make a complaint should they need to. One resident said all the staff of very approachable and helpful. Another resident wrote we all have a key worker and if theyre not available the manager will always see us when she is free. The self assessment told us Complaints are responded to as fully as appropriate within 15 working days. We always apologise for mistakes or bad practice, and take action to remedy things. Our aim is to satisfy the complainant as quickly as possible, but where we do not they are given the information to take the matter further. Our published procedure gives details of the local CSCI office. We requested to see the records of complaints made in the previous 12 months. We were aware of one complain that related to a resident being asked to leave the service however upon investigation the service changed their mind and agree that they could meet the individuals needs. The documentation relating to this complaint was available for inspection. Records relating to other complains were kept in a log book that was Care Homes for Older People Page 19 of 29 Evidence: available to everyone and not confidential. Records held in this document related to matters such as concerns around catering. We therefore recommended to the manager that a confidential log of complaints is kept of all complaints made and this should be available for inspection. All 3 staff spoken with were aware of the complaints procedure and what to do if a resident expressed any concerns. We asked 4 different staff on duty had they received training in abuse awareness and what would they do if they had concerns. All staff said yes they had received training and were aware of their duty to report any concerns and would whistle blow if the need arose. We were made aware of one referral made by the home of a safeguarding referral and it was confirmed that this matter had been appropriately reported to social services and the matter was investigated and concluded. The manager confirmed that she and a senior member of staff were to attend NAPPI (Non abusive Psychological and Physical Intervention) training that would allow them to cascade the training to all staff at the home. Even though the home had referred this matter correctly, on the day of inspection the policy and procedure relating to safeguarding and abuse could not be located and was not available for inspection. The manager gave an undertaking to obtain the policy and procedure and and have it available for staff and any one who wanted to see it. We also gave information on the local social services website where this and other information could be located. Care Homes for Older People Page 20 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service can expect to live in a clean, safe, attractive, well designed home that meets their needs. Evidence: The Martins is a purpose built and well designed home for older people and older people who have dementia. The purpose built home is constructed on an incline, therefore has a lower ground floor, which is Lark Close, a ground and first floor that are the main part of the home. The Home has 42 single rooms, each with en-suite WC facilities. Residents rooms seen were all individualised with personal pieces of furniture, ornaments and pictures. Communal areas in the main home comprise a large sitting room and dining room, both of which have entrances onto the veranda and a second lounge on the ground floor. There is an additional sitting room on the first floor equipped with tea making facilities. There is a purpose built hairdressing salon and a small courtyard in the middle of the Home. Lark Close is more compact, designed in a simple L shape. It has a kitchen/diner and two lounges for communal space as well as individual bedrooms. It also benefits from a secure sensory garden containing sculptures, seating and scented plants. On the 2 days of inspection everywhere in the home was clean and tidy with no Care Homes for Older People Page 21 of 29 Evidence: unpleasant odours. What was particularly pleasing was the smell of fresh flowers around the home and freshly brewed filter coffee seen in 2 places. The decor was attractive with a selection of interesting pictures and ornaments in the wide corridors that give a feeling of spaciousness to the building. A large number of the rooms look out over the ruined abbey and Abbey Gardens with the Cathedral on the skyline. Residents spoken with commented on the inspiring views from the windows and the closeness of the community that they could access. A tour was made of the whole home on the first day with the manager and she spoke of her plans to have the call bells system upgraded. This included having mobile call bells and longer cords in rooms so that residents could more easily summon help should they need it. On the second day we saw that a new dishwasher was promptly order and delivered in one day so that residents and staff were not without a facility to clean dishes in Lark Close. Whilst touring the home we found it to be light and airy with all radiators covered to prevent harm. The laundry was clean and tidy. Hand washing facilities in the home were all equipped with liquid soap and paper towels. We also found on the first day that a shower was out of order, a bath panel had a hole in the side and the seal to the same bath was brown and that a second bath had a notice on it about a fault being identified in September 2008. We requested that the manager review the bathing facilities currently on offer in relation to the needs of the current resident group. On the second day of our visit she was able to show that this matter was under consideration and said that one bath was to be replaced and the second with the fault had passed a recent technical inspection and was safe to use. Care Homes for Older People Page 22 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service can expect to be supported by adequate numbers of correctly recruited and well-trained staff. Evidence: In relation to the amount of staff on duty to meet the needs of the residents we believe that this is currently satisfactory. From staff surveyed they tell us that the staffing levels are about right, but 3 staff spoken with on the day of inspection felt that the needs of the residents in the residential part of the home had increased. One staff member said today there is 2 staff for 19 residents in the residential side and this is not enough. We spoke with the manager about this and she was aware that the needs of some residents had increased and she was ensuring an additional staff member was available when possible and this was most of the time. From the 9 surveys completed by residents 3 residents said that staff were usually available when needed. The other 6 said staff were always available when needed. One resident wrote All bells are answered but if there is an emergency we wait a little longer. We in turn are checked to see if we too need urgent attention, if not we are asked to wait. On the day we asked 2 residents if call bells were answered promptly and both said that they were. We examined records on staff recruitment and found that all the required pre employment checks were in place. Staff surveyed said that checks such as CRB and Care Homes for Older People Page 23 of 29 Evidence: references were carried out before they started work. The manager spoke of recruiting more staff and that she was monitoring staff turn over to see if this was satisfactory. In relation to staff training the self assessment told us Our ratio of NVQ qualified care staff is currently 95 , which will rise to 98 once the staff currently training complete the qualification. Training is monitored daily through a Matrix system that is connected to head office. Additional mandatory and new ELearning courses are available for staff. 17 staff completed Level 2 Dementia Awareness Diploma, 1 staff did 6 month course in Infection Control. I member of staff did a Diploma in Health & Safety 6 month course. 7 staff have their NVQ Level 3 and 2 more staff are qualifying NVQ Level 3. New ELearning courses are being made for staff. Staff whose first language is not English are going to the Local College, they are completing ESOL Training to help them with literacy and numeracy and Basic skills. The manager had identified training for the coming year and this included manual handling and fire training for staff and also more dementia care training for staff. This time it was to be delivered by the Alzheimers society. Staffed surveyed and spoken with felt that the training offered was satisfactory and covered all that they needed to know and 2 staff had identified that they would like more dementia care training. Care Homes for Older People Page 24 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Martins was satisfactorily managed in a person centred way with the interests of the residents considered. The health, safety and welfare of people is monitored and maintained. Evidence: There is a new manager appointed to this service and she started in post on 15th December 2008. The manager holds an NVQ 3 in care and Independence and has the registered managers award. She explained that she is currently undertaking a degree in dementia care with Bradford University and had previously completed training in dementia mapping. The management structure within the home has altered and a deputy manager had also been recruited. We were able to meet both the deputy manager and the area manager during our visit. We spoke with 3 staff about the new manager at the home. All were positive saying that they agreed with the changes that she was making, that they found her supportive, responsive and approachable. Care Homes for Older People Page 25 of 29 Evidence: In relation to quality assurance the self assessment stated We are proud of our Quality Assurance programme, set out in our Quality Policy and including an annual self assessment (Standards and Values Assessment) (The Martins was won the Most Improved Home 2008 and scored 94 in the last SVA) carried out be senior advisers in MHA, a 6 monthly internal audit involving residents and junior staff, annual resident satisfaction survey, and internal Management review including a clear business plan and action plans from internal and external audits. We ensure residents are receiving high standards of service by seeking feedback from them, their families and health care workers to this end. We also asked to see a copy of the regulation 26 visits completed by the organisation when they visited the home. The current manager was able to find October and November 2008 for us to see. In relation to service users money there is currently a system in place where by Methodist Homes does not make any financial decisions for residents but, they keep small amounts of money available for residents. The manager confirmed her intention to review the current system in place to ensure it was as safe and secure as possible. In relation to staff supervision staff on the whole felt supported and that management was available to them. There had a been a recent staff meeting at the home. In relation to more formal supervision the feed back from staff and evidence on staff files was that this perhaps has stalled a little in the transition from one manager to another. This was fed back to the manager who was aware. Displayed around the home were various awards that included a certificate relating to patient safety hydration best practice award. Also a certificate for food hygiene award for 2008. The self assessment told us that in relation to health and safety all equipment was serviced appropriately. We sampled some records and found that the fire alarm and other related testing was regularly in place, hot water temperatures were regularly tested and were within safe limits and randomly selected a hoist and found this had been regularly serviced. The manager confirmed it was her intention to review the fire risk assessment currently in place at the home. Care Homes for Older People Page 26 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 7 7 Risk assessments should be completed in an individualised way that is person centred and not a blanket approach. Care plans for new residents should be completed in a more timely manner to ensure that key care needs are known immediately by staff to ensure health does not deteriorate. When the medication fridge temperatures rise remedial action should be taken to reduce temperatures to ensure medication is stored correctly. It is good practice to have available the policy, procedure and referral information about safeguarding this will ensure that all have free access to the information, but particularly if it is needed in a hurry to promptly safeguard residents. 3 9 4 18 Care Homes for Older People Page 28 of 29 Helpline: 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 We want people to be able to access this information. 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