Care Home: St Martin`s House

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What the care home does well Staff told us that they receive a variety of good training, to include regular fire training, mental health training, induction training, medication training, venepuncture and Protection of Vulnerable Adults training. They also said that they felt the staff team was working well as a cohesive team. Residents told us that the majority of staff were excellent. They have the opportunity to engage with therapists on a one to one basis and also take part in various other activities and interests.St Martin`s HouseDS0000008910.V377435.R01.S.docVersion 5.2The food provided is varied and to a good standard. Individual needs and choices are provided for. Employment policies and procedures are followed to ensure that vigorous checks are made as to the individuals suitability to work in a care environment. The manager has worked hard to improve the service provided. Head Office staff undertake monthly quality audits and reports required by regulation 26. Dementia mapping is regularly undertaking and we had the opportunity to view the outcomes of the most recent results which were positive. What has improved since the last inspection? The care staff are supportive of each other and are working well together. On the day of this unannounced inspection there were a total of 11 nursing and care staff on duty plus the manager and other support staff. The total number of people in residence at the time of the inspection was 33. The care planning format introduced approximately twelve months ago is seen to be working well. Records are well kept and up to date. A full time Housekeeper has been employed, supported by domestics, and the standard of hygiene and cleanliness has improved. Improvements to the environment include redecoration to certain areas of the home, particularly the kitchen. New carpets have been laid and improved lighting installed. The small dining areas attached to lounge areas now have hard flooring which has improved hygiene considerations. The enclosed garden was well presented with numerous flower baskets tended to by residents. Two statutory requirements and three recommendations were made at the last inspection. These have all been complied with. Care plans are now regularly reviewed at monthly intervals and staff are receiving regular supervision. The kitchen area has been subject to thorough cleaning and redecoration. The manager and her staff have worked hard to improve the home which has resulted in a two star rating being awarded. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 What the care home could do better: We have awarded a "good" rating to the environment section of this report in recognition of the hard work achieved by the housekeeper and her staff. The improvements to the premises was also taken into consideration. It must however be said that St.Martins is an old purpose built building that does not fully comply to modern standards. We were informed that Cornwall care plan to replace this home with a new build within the next five years. The complaints policy did not contain the address of the local Department of Adult Care Services. The manager undertook to add this address immediately. Key inspection report CARE HOMES FOR OLDER PEOPLE St Martin`s House St Martins Crescent Camborne Cornwall TR14 7HJ Lead Inspector Mike Dennis Key Unannounced Inspection 1st September 2009 09:00 DS0000008910.V377435.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Martin`s House Address St Martins Crescent Camborne Cornwall TR14 7HJ 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) 01209 713512 01209 711444 stmartins.home@cornwallcare.org Cornwall Care Ltd Vacant Care Home 40 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (22), Mental disorder, excluding learning of places disability or dementia (3), Mental Disorder, excluding learning disability or dementia - over 65 years of age (22), Old age, not falling within any other category (18), Physical disability (3), Physical disability over 65 years of age (18) St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Service users to include up to 18 adults of old age (OP). Service users to include up to 18 adults with a physical disability (PD[E]). Service users to include up to 22 adults aged over 65 with a dementia (DE[E]). Service users to include up to 22 adults aged over 65 with a mental illness (MD[E]). Total number of service users not to exceed a maximum of 40. Up to 3 Service Users over the age of 59 and below the age of 65 in the categories Dementia (DE), Mental Disorder (MD) and Physical Disability (PD). The total number of Service Users not to exceed 40 9th September 2008 Date of last inspection Brief Description of the Service: St Martins House is one of eighteen care homes owned by Cornwall Care Ltd. It is registered to accommodate forty older people in need of personal care and nursing who are over retirement age. A limited number of people attend day care at the home. This care home with nursing provides long term care to service users who are in need of personal care and/or nursing care and are over retirement age. Admissions are planned and emergency admissions are avoided whenever possible. Day care is available at St Martins House for 1-3 service users a day. The facilities for residents are on a single floor, which is accessible to all service users. All service users rooms are single occupancy with access to lounge areas and toilet facilities. Service users can access a secure garden. St Martins House is close to the facilities of Camborne and has good transport links to the town. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced inspection took place over a period of approximately 7 hours on the 1st. September 2009. We met with the manager, staff, and residents, and toured the premises, as well as inspecting relevant documentation. The key inspection focused on the premises, meals, medication, records relating to care, staffing and management to include policies and procedures. Case tracking of four people took place and some of these people were spoken to during the course of the day. Mostly positive comments were received in relation to the care that they are receiving at the home. For example: “I get regular visitors and I like my privacy, which the staff respect”, “I get a choice of meals and have a nice room, I would not like to be anywhere else”. It is noted that the physical care needs of a number of the people at St. Martins are high. The Manager completed the Annual Quality Assurance Assessment form. We are grateful to the manager, staff and residents for their assistance in completing the inspection. What the service does well: Staff told us that they receive a variety of good training, to include regular fire training, mental health training, induction training, medication training, venepuncture and Protection of Vulnerable Adults training. They also said that they felt the staff team was working well as a cohesive team. Residents told us that the majority of staff were excellent. They have the opportunity to engage with therapists on a one to one basis and also take part in various other activities and interests. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 6 The food provided is varied and to a good standard. Individual needs and choices are provided for. Employment policies and procedures are followed to ensure that vigorous checks are made as to the individuals suitability to work in a care environment. The manager has worked hard to improve the service provided. Head Office staff undertake monthly quality audits and reports required by regulation 26. Dementia mapping is regularly undertaking and we had the opportunity to view the outcomes of the most recent results which were positive. What has improved since the last inspection? The care staff are supportive of each other and are working well together. On the day of this unannounced inspection there were a total of 11 nursing and care staff on duty plus the manager and other support staff. The total number of people in residence at the time of the inspection was 33. The care planning format introduced approximately twelve months ago is seen to be working well. Records are well kept and up to date. A full time Housekeeper has been employed, supported by domestics, and the standard of hygiene and cleanliness has improved. Improvements to the environment include redecoration to certain areas of the home, particularly the kitchen. New carpets have been laid and improved lighting installed. The small dining areas attached to lounge areas now have hard flooring which has improved hygiene considerations. The enclosed garden was well presented with numerous flower baskets tended to by residents. Two statutory requirements and three recommendations were made at the last inspection. These have all been complied with. Care plans are now regularly reviewed at monthly intervals and staff are receiving regular supervision. The kitchen area has been subject to thorough cleaning and redecoration. The manager and her staff have worked hard to improve the home which has resulted in a two star rating being awarded. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 7 What they could do better: 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home’s statement of purpose and service user guide documentation provide prospective people with details of what the home provides helping an informed decision about admission to the home. At the initial pre admission assessment people are informed that this information can be supplied via large print, audio cassette and possibly in brail. The manager assesses all people prior to admission to the home to ensure that the home will be able to meet their care needs. People may visit the home prior to admission. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 10 EVIDENCE: Information is given to prospective residents by way of a Statement of Purpose, Service users Guide and brochure. We looked at these documents and found them to be up to date and they reflected the service being provided at the home. This documentation was also available in large print, audio cassette and brail All people using the service had agreed to a contract of care and/or terms of conditions. The Manager and senior nursing staff complete needs assessments for prospective residents and obtain assessments from the commissioning authority. Cornwall Care Ltd has a standard format for assessment and care planning, which, when completed in sufficient detail, covers all the issues specified in the standard. The four residents’ records case tracked in detail contained written needs assessments. Commissioning information from health and adult social care was also on file. Assessments stated who was present, providing evidence that the prospective resident and their family were involved in the assessment. People are able to visit the home and consider for themselves if they wish to become resident. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents health, personal and social care needs are set out in individual plans of care which have regularly reviewed. Medication procedures are appropriately followed. The majority of residents report satisfaction with their health care. EVIDENCE: All the residents case tracked had written care plans. Cornwall Care Ltd has a standard single format for assessment and care planning. This system used is the Standex System. All care recording in this home is now documented on this format. St Martin’s staff also draw up a ‘Care Profile’ - a summary of the care plan used as a working document. The care plans and care profiles directed and informed care staff on meeting the health, personal and social care needs of residents. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 12 All residents case tracked had a moving and handling assessment. Falls risk assessments are compiled allowing staff to conduct overviews on these incidents. This information can feed into a review of the care plan. We noted that all care plans seen had been reviewed at the required monthly intervals. There was a clear direction for staff about assistance with mobility. Daily records were completed consistently and generally to a good standard. Comprehensive information was presented to detail hobbies, interests and activities pursued by people. Staff keep separate daily records in respect of bathing, and, where required other specific individual care needs. Residents are all registered with local GP practices. The majority of residents and their representatives felt that their health care needs were well-monitored and appropriate attention obtained. St. Martins does care for some very dependent people and it is recognised that the care input can be intense and challenging. Care planning and the consistent implementation of care delivery is therefore all important. Staff maintain a record of medical contacts for each resident. The community nurses visit the home regularly. Medicines are stored in locked trolleys and in locked cabinets in a locked room. The room and cabinets were tidy and well organised. There is a small medicines refrigerator and the temperature is checked daily. The monitored dosage system is in use. Some residents administer their own medication. Residents sign an agreement to the administration of medicines. Cornwall Care has a corporate policy and procedure on the handling of medicines which includes guidance on the use of homely remedies. The administration records were complete and well maintained. Samples of stocks were checked against the medicine administration record and found to be accurate. The controlled drugs are stored in a secure controlled drugs cabinet. A sample of controlled drugs was checked against the record and found to be accurate. Unused/unwanted medicines are disposed correctly via the appropriate disposal bins. Records are kept of all medication disposed. The temperature of the storage room must not to exceed 25C, and this is monitored. Creams/lactulose etc. are all contained in individually named pots. It was also positive to note that alcohol gel was available on the medication trolleys and being used. Residents provided positive comments on the skills and caring qualities of staff. They felt that staff worked sensitively with them when assisting with St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 13 personal care and respected their privacy and dignity. Examples of staff delivering appropriate and sensitive care were noted during the inspection. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported to follow a lifestyle which accords as far as possible with their own choices and preferences. The diet provided is varied and nutritious with attention to individual preferences. EVIDENCE: The majority of residents commented that there is ‘enough to do’ during the day. A variety of activities were taking place or planned. These included socialising in lounges, head massage, crafts, art, music, bingo, reflexology, outings and receiving visitors. Staff discuss activities with residents so that they can choose whether to participate. Residents told us how much they enjoyed the activities. Some residents commented that they prefer to spend time in their own company and this is respected. Individual interests are recorded in service user admission information, care plans and their life story record. We observed a high level of staff input to the nursing areas. The care staff were also observed to be busy caring for residents. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 15 There is a flexible visiting policy and residents determine where they meet their guests. Residents felt their visitors were welcomed to the home positively and could not think of improvements in this area. Visitors confirmed that the home’s visiting arrangements suit them and that generally staff make them welcome, offering, for example, a cup of tea. The Manager stated that she does not act as appointee for any resident for their benefits or manage any savings. A minority of residents manage their own finances. Other residents’ finances are managed with informal assistance from relatives or through Power of Attorney arrangements. Residents can bring in possessions and furniture by agreement with the provider. Cornwall Care Ltd has introduced the ‘appetite for life’ initiative to ensure that a varied and appealing diet is provided to residents in a relaxed atmosphere. The cook reported that they have continued to review their 4-week menu and take account of residents’ wishes. There are two main choices each day at lunch, with further choices also available. The home is currently providing some diabetic diets and low fat diets. Some residents receive assistance with eating. Residents made positive comments to us concerning the food provided to them. Staff were seen helping residents with their food intake. Residents choose where to have their meals, either in their room or in the wing dining area. Residents enjoyed a sherry or glass of wine and their choice of meal. Residents reported that they had a good choice of breakfast, and a range of savouries and puddings and cakes at tea. Drinks are served between meals. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 home has a satisfactory complaints procedure that would ensure that complaints are listened to and acted upon. There are arrangements to protect service users from abuse. EVIDENCE: Cornwall Care Ltd has a corporate complaints procedure. Any complaints received at the home have been investigated by management personnel. The Manager keeps a record of compliments. Residents told us that they knew how to make a complaint. Residents and visitors told the inspector that they would approach the managers at the home with any concerns and these would be addressed. Cornwall Care Ltd has an adult protection policy and procedure. Cornwall Care staff in general respond appropriately to incidents and concerns about adult protection and follow the local Multi-Agency Adult Protection Guidelines. The company’s own policy and procedures are in line with Multi-agency Safeguarding procedures. The majority of staff have received training in adult protection. The Induction programme for all new staff includes Safeguarding training. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 17 The complaints procedure should contain contact details of the Department of Adult Care Support. The manager undertook to remedy this deficit on the day of inspection. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 home is generally well presented. Residents live in a clean and hygienic environment which is maintained. EVIDENCE: The residents’ accommodation at St Martins House is on the ground floor and is accessible to all service users. A small area of the building is used for offices. The home is arranged in four wings. Each wing is a self-contained unit with bedrooms, dining area, lounge, toilets and bathrooms. There is a garden which is accessible to residents. Bedrooms are single occupancy. These rooms are quite small, but are pleasantly decorated and furnished. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 19 St Martins is situated in a residential area of Camborne not far from the facilities and services of the town. The car park leads to the main entrance which is suitable for wheelchair users. The provider has a redecoration and maintenance programme aimed at ensuring that all parts of the home are presented and maintained to a good standard. The cleanliness of the home was observed to be of acceptable standards. Additional support staff have been employed to maintain hygiene and cleanliness. It is evident that the Housekeeper and her staff work hard to maintain standards. In particular the kitchen has been re-decorated and a marked improvement is noted. Residents stated that they are satisfied with the presentation and the quality of furnishings. The rooms inspected were clean and decorated to a good standard. The rooms were personalised and residents had the option to lock their rooms. The laundry complies with the standard. The washing machines and tumbler driers are industrial standard. Guidance notices are posted for staff. Residents commented that the laundry service is ‘good’, with their clothes being kept clean, and did not raise any issues in this area. The bathing and toileting facilities in the home comply with the standard, providing assisted baths and a level entry shower. Toilets are suitably close to communal areas. All the bathrooms and toilets inspected were clean and hygienic. Facilities for hand washing with hand wash, paper towels and alcohol rub were situated throughout the home. Aids and adaptations were evident to assist with mobility and transfers. There were sufficient sluicing facilities in the home. We conducted a tour of the building between 12:00 and 13:00 hours. At this time several residents were having their Lunch and there were plenty of staff in attendance. Odour control throughout the home was satisfactory. Bathrooms and toilet areas were freshly cleaned and hazard warning notices were in place. Carpeting in many areas have been replaced with new. Based on the above considerations we have awarded a good rating for the environment. It must be said however that the building does not fully comply with modern standards. Cornwall Care are aware of this and we understand that St.Martins is part of their intended re-build programme. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment procedures support and protect the service users. Staff are trained and competent to meet the needs of residents. The staffing levels are generally satisfactory. EVIDENCE: Residents commented that they felt staffing levels were sufficient, although some remarked that staff were kept busy. There has been an increase in staffing levels since the introduction of nursing care. Overall it is considered that staffing levels are satisfactory but care must be taken to ensure they are evenly dispersed throughout the home. No complaints came forward about the skills and qualities of the staff team. In fact we were told and observed a good team spirit amongst the staff team. On the day of this unannounced inspection we consider that the home was well staffed by management, nurses and care staff. A recent summary of training records showed that the majority of staff have achieved NVQ awards St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 21 Qualified nursing staff are employed and all are checked to have current registration through their governing body the NMC. The training records for nursing staff clearly identified their training needs. . All staff are recruited following set down company procedures. We tracked this process in respect of six staff and found that all had been competently managed to include application forms, references, proof of identity and CRB and POVA checks. Cornwall Care Ltd provides a structured training programme for staff. Training records showed that staff were up to date with required training in moving and handling, dementia care, food hygiene and health and safety. Senior staff have also had training on the Mental Capacity Act and Deprivation of Liberty Safeguarding. Recently appointed staff had begun their inductions. Staff made positive comments about the training they received to do their jobs. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 home has an experienced and qualified manager. The health and safety of residents and staff are promoted and protected as are their financial interests. The manager and staff have worked well to improve the standard of care. EVIDENCE: The home does not have a Registered Manager at this time. The Manager has been in post for just over 12 months and has submitted her application to be registered. This process would have been completed by the time of this St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 23 inspection. She has been successful in applying for a similar position within the company and her application has therefore been transferred. She is experienced and holds a Foundation Degree in Management, NVQ 4 and is an NVQ assessor. She also has certificates in Dementia Mapping and Dementia Care. The Lead Nurse also fulfils the Deputy Manager position. Cornwall Care Ltd has corporate policies for the management of service users’ monies. Service users are encouraged to manage their own monies and hold their own accounts. Cornwall Care Ltd provides safekeeping for small amounts of money. The records show all payments in and out and a running balance. The Manager reported that an inventory is now retained for all valuable items also held for safekeeping. Cornwall Care Ltd annually seeks the views of residents and their representatives, and other stakeholders through questionnaires. In addition a head office representative conducts monthly audits to establish the quality of care, residents views, record keeping and the overall management of the home. We looked at the staff supervision records and also spoke to several care staff. The resulting conclusion being, that staff have received regular supervision. Cornwall Care Ltd has comprehensive policies for health and safety. A sample were checked against the original records and found to be accurate. Staff have attended relevant health and safety training. Staff reported that Cornwall Care Ltd promotes safe working and manages health and safety well. The records showed weekly tests of the fire alarm system, monthly tests of the emergency lighting and regular fire training for all staff. All other maintenance contracts and certificates were seen to be up to date. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 2 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP16 Good Practice Recommendations Add the contact details of the Department of Adult Care Support to the complaints procedures. St Martin`s House DS0000008910.V377435.R01.S.doc Version 5.2 Page 26 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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