Care Home: St Martins

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What the care home does well Residents and relative Survey’s confirmed to us a high percentage of satisfaction with standards of care provided. St Martin’s staff allocation is good and the different roles and senior structure within the house ensures that all residents’ needs are met consistently. The safeguarding of all medication is maintained for all people, there are regular checks every shift, weekly and monthly. Staff are very friendly and make visitors feel welcome and the manager and her team organise records well and information held within them is relevant. The environment has been moulded around residents needs particularly with dementia or confusion, this has allowed residents to be able to be independent as much as possible from staff to use the different areas. What has improved since the last inspection? All care files have been updated and better organised. Areas of the home have been developed in terms of supporting people specifically with dementia. St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Residents have a wide choice of activities to choose from. What the care home could do better: CQC has no requirements at this present time, although it is recommended that the Garden could be improved by building a pathway around the back garden to allow people with dementia to wander around independently as this would provide further stimulation and act as an extra activity. Key inspection report CARE HOMES FOR OLDER PEOPLE St Martins 59 Imperial Avenue Westcliff On Sea Essex SS0 8NQ Lead Inspector Sarah Axam Key Unannounced Inspection 11th September 2009 10:00 DS0000015469.V377025.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 Martins DS0000015469.V377025.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 Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Martins Address 59 Imperial Avenue Westcliff On Sea Essex SS0 8NQ 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) 01702 475891 01702 471631 sue@stmartinscare.org The Mission of Help Ms Susan Joan Field Care Home 29 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (28), of places Physical disability (1) St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Care for residents with a physical disability is restricted to one client whose details are known to the Commission. Number of service users for whom personal care to be provided shall not exceed 28 (total number to not exceed 28). Personal care to be provided to no more than 28 older people over 65 years of age. (total number to not exceed 28). Personal care to be provided to no more than 28 service users with dementia over the age of 65 years of age. (total not to exceed 28). 26th June 2008 Date of last inspection Brief Description of the Service: St. Martins is a large older style detached building situated in a pleasant residential area in Westcliff-on-Sea. The home is close to public transport, the beach, a large park and local shops. The home provides accommodation and support for up to twenty-six older people, all or some of whom may suffer from dementia. Additionally the home has a condition of registration, which allows it to offer care to one named person, who is under sixty-five and has a physical disability. Rooms are provided over three floors with a shaft lift connecting the floors as well as stairs between the ground and first floor. Accommodation comprises of 24 single and 1 shared bedrooms, 6 of which have en-suite facilities. The home is gradually changing the shared facilities to single rooms thus reducing the number of places available. There are two separate lounges, a large, attractive dining room, a small quiet room for visitors and a conservatory lounge which leads out to a large well maintained attractive garden. There is limited parking to the front of the property. All prospective residents are provided with a Statement of Purpose and Service User Guide that supplies them with up to date information on the home. Fees range from £352.10 to £630.00 monthly but do not include the cost of hairdressing, chiropody, taxis, newspapers, outside visits and holidays. St Martins DS0000015469.V377025.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 *3 star. This means that the people who use this service experience Excellent quality outcomes. The unannounced site visit took seven hours to complete and was carried out as part of the annual inspection programme for this service. This visit was conducted with assistance from the manager, deputy manager and duty officer. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. We looked at all the information that we had received, or asked for, or what the service has told us about things that had happened in the service since the last inspection. Four staff, three residents and two relative were spoken with during the site inspection. Prior to this site visit, CQC (Care Quality Commission) sent out surveys to all interested parties and 10 were returned to us. Additionally the manager was sent an (AQAA) Annual Quality Assurance Assessment form by us. This is a self assessment required by law that asked how well the service is meeting the needs of the people who live at St Martins Care Home. All information obtained was triangulated and reviewed against the commissions key lines for regulatory activity. This helps us to use the information to make judgements about the outcomes for the people who use this service in a consistent and fair way. What the service does well: Residents and relative Survey’s confirmed to us a high percentage of satisfaction with standards of care provided. St Martin’s staff allocation is good and the different roles and senior structure within the house ensures that all residents’ needs are met consistently. The safeguarding of all medication is maintained for all people, there are regular checks every shift, weekly and monthly. Staff are very friendly and make visitors feel welcome and the manager and her team organise records well and information held within them is relevant. The environment has been moulded around residents needs particularly with dementia or confusion, this has allowed residents to be able to be independent as much as possible from staff to use the different areas. What has improved since the last inspection? All care files have been updated and better organised. Areas of the home have been developed in terms of supporting people specifically with dementia. St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 6 Residents have a wide choice of activities to choose from. 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 Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 7 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 Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 8 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): 1,2, 3,4,5 and 6 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. A clear and comprehensive assessment process assures people that their needs could be met prior to moving in their home. EVIDENCE: The manager told us in the Annual Quality Assurance Assessment that there is a statement of purpose and residents guide, which provides information about the home to help people decide if they would be happy there. The manager told us that a needs assessment is carried out and that people are invited to visit the home before they move in and once they do a contract would be agreed. St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 9 When we visited the home we looked at nine residents files and saw that these were in place. We saw that there were visits made; assessments carried out and peoples involvement within this process. We saw pre-admission assessment included looking at issues such as, continence and sensory monthly check wear dentures, chiropodist, glasses, and hearing aid etc. Then a dependency profile was put into place covering issues, such as, mobility, bathing, sleep, personal hygiene, personal safety, cognitive ability, falls, continence, breathing, medication, behaviour, sociability, transferring, oral hygiene, feeding, skin and tissue viability, memory, speech and communication, sensory ability, bowels, dressing and mood. One of the relative visiting the home told us that they had plenty of visits, chats with the manager and staff and information given before their relative moved into St Martins. The three residents who completed surveys (with the help of their relatives) told us that they had good information before moving in. We saw that statement of purpose and residents guide is in place. These documents gave information about the staff structure, their qualifications, the complaint process, support, accommodation, local area, health and specialist services and activities. At present there are two resident vacancies at St Martins Care home. St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 10 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): 7,8,9,10 and 11 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 assessed needs are followed through in good care plans that give staff the necessary information to provide good care outcomes. EVIDENCE: When we visited the home we looked at how the personal and health care needs of the residents were assessed and how residents were supported. The health care plans of all 9 residents showed us that they were actively consulted, that views were recorded, and that risk assessments were current and reflected the persons support needs. Health care issues assessed included, physical, mental, dietary, personal care, independence, emotional and wishes of individuals if their health deteriorated for any reason. Through all documentation held there were minutes of meetings, letters and conversation recorded with a number of other specialist services, such as Community St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 11 psychiatric nurses, consultants, social workers and generally a number of NHS community facilities. When we visited the home we saw that the medication administration records were maintained in accordance with agreed procedures and the royal pharmaceutical legislation. At the time of the inspection none of the residents living in the home were capable of safely keeping and administering their medicines, therefore a monitored medication dosage system is in place for each resident. We looked at medicine administration records and these were completed accurately to show that residents received the medicines, which were prescribed for them. We saw that all staff training was complete and upto-date. Medication is checked between the changing shifts everyday and every week the deputy checkS this and manager monthly audits go ahead. There have been no incidents reported around medication issues or practice. This would suggest that medication is kept to a strict protocol and is maintained consistently to a high standard which ensure peoples protection. St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14 and 15 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. People using the service can be confident that their identified needs will be met appropriately and that they will be able to live the lifestyle they choose. EVIDENCE: When we visited the home we looked at all of the residents care plans. We saw that all residents had a plan of care which described their wishes for the activities they wish to participate in. We looked at records kept by staff about the activities that all residents participated in. It was clear that the activities were suitable for the resident and they included pursuits, which the resident liked to participate in. Activities included things such as, entertainers, singers, dancers, mobile museum which consists of toys, magazines, wedding dresses gas marks, ration books from the war time period. The activities coordinator has just left after many years of being in post and the manager is presently looking for a new replacement in the meantime one of the trustees is filling in this role. The activity coordinator carries out St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 13 activities with people such as, indoor golf, draughts, art, foot bath and hand massages, soft ball games, a number of board games, flower arranging and use of the garden with various activities. Apart from this there are still plenty of stimulation for the residents, such as, dominoes, indoor bowls, gardening, story writing, pen friends, snooker, card games, movement to music, flower arranging, stamp collecting, drawing and painting, sewing, knitting, poetry, board games, photography, quizzes, reading, jigsaws, singing, baking, crochet, handicrafts, memory albums reminiscing, photos, personalised cards and gifts. The residents have recently purchased a Nintendo Wii, staff report that the residents enjoy this very much even if they are just watching others. The manager told us that she intends to get some fitness games as well so that people can join in some form of exercise. Many outside outings are arranged, such as, concerts, cinema, theatre, art displays, garden centre, farms, pubs, museums, fish and chips, seaside, libraries, and countryside and shopping. Additionally just down the end of the road is, Chalkwell Park, which is frequently used by the residents, especially when the fair is held there twice a year. The manager told us that they have recieved support and help from a local Brownies Pack, Local Infant School, Rotary Club, Lions and Ladies Circle that come into the home and visits that the residents enjoy very much. Residents who returned surveys and that we spoke to confirmed that they had plenty of activities and stimulation provided that were of their choice. Residents have the opportunity to have friends, family and people important to them visit and take meals with them. This was confirmed to us by speaking with a relative and surveys returned to us. The manager told us that she arranges events which all people that are important to residents can attend and these events tend to have themes, such as, a beach day was held and the manager arranged to have a Punch and Judy show, candy floss etc. Another theme was Easter and an egg hunt was arranged for residents and their families to join in. Social Events are held which include family, friends and the local community. The manager told us that they aim to have at least one big social event each month, such as a Cockney event bringing memories of the East end, Garden Party to dress up and socialise, Cream tea to Indulge, etc. The manager told us that they have introduced activities that include and maintain life skills where residents help staff with washing up, laying tables, cleaning brass, preparation of vegetables, making sandwiches. This is done in a small group ending up talking about past times over a cup of tea. People told us that they can get up and go to bed when they want a mobile hand set that they can use in private and is hearing aid compatible. One person goes regularly to their local church every Sunday and other people have the priest come in and receive Holy Communion. (There is a designated private space for this within the home) People can still continue to vote in local St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 14 and government elections if they wish and they receive their own mail and can make private phone calls if they wish. We saw that residents and the relatives have regular monthly meetings and issues such as, previous minutes of meetings, activities, meals, staff issues (leaving and new staff) and any other issues people may have are discussed and recorded. We looked at the arrangements for supporting residents when choosing and preparing food and meals. We saw that staff supported residents in buying food supplies from the supermarket and preparing food and that there was a planned menu, which reflected residents likes and dislikes. Each resident had a care plan which described the support the individual needed. One person spoken with told us that they went out regularly to choose food and observation showed us that before meals were prepared all residents were asked what they wanted to eat. We saw that there was a four week menu in place that showed us that the likes of residents that were recorded in their information were reflected in the meals provided and that they had a varied and good quality of diet. The menus offered people two choices of vegetarian meals and two traditional meat based meals and two choices of puddings. In between meal times, observation showed us that people had a choice of savoury, sweet snacks, cakes, and hot and cold drinks. The manager told us and showed us that a new pictorial menu board is presently being developed this will allow people to have a greater choice in the meals provided to them. St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 15 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): 16 and 17 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. There are systems in place to ensure that peoples views are listened to and acted upon and that support people to be protected against abuse. EVIDENCE: We were told in the Annual Quality Assurance Assessment that any complaints or safeguarding alerts would be dealt with openly and thoroughly. The manager told us that resident’s relatives are provided with information on how to complain and how their concerns would be dealt with. The manager told us that there had been no formal complaints made about the service within the past twelve months. They also told us that staff received information about dealing with complaints and whistle blowing when they commence work at the home. When we visited the home we looked at the policy and procedure in place for recording and dealing with complaints. The manager has a good complaints procedure in place. All complaints were recorded, maintained and outcomes recorded. All seven staff surveys returned told us that they felt, they knew what course of action to take if there was a concern or complaint that was made. Four residents told us that they felt the manager and staff listened to them and felt that if they raised a concern then it had been dealt with satisfactory. St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 16 There was a safeguarding policy and procedure in place and the manager told us that all staff were given this information when they commenced work at the home. Three members of staff were on duty during the inspection and they told us that they had received safeguarding training and they demonstrated that they understood their responsibilities if they witnessed or suspected any ill treatment of residents. There was a whistle blowing policy which staff had access to and when speaking with staff they told us they were aware of this. This helps assure staff that they will be protected from harassment should they need to raise concerns about the home or other staff. We saw that all staff had received safeguarding training to keep them up to date with local policies and procedures and help ensure that all concerns would be treated properly. St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 17 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): 19, 22 and 26 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. People live in a clean and safe environment. EVIDENCE: The manager told us that the home has changed its corridors into small themed areas and Communal areas, linking bedroom doors and bathrooms in each area. This helps resident recognise different areas and space through colour and stimulation. This forms an aid to encourage independence, reduces confusion by decreasing the likelihood of becoming lost. Stimulation on and around the walls helps to keep memories fresh and preserved for as long as possible. St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 18 We took a tour of the building and we saw that in the nine different areas of the home the staff were gradually completing themes such as, sea side, artist area (the home has a couple of resident artists), reminiscence (cabinet full of old style house hold items), fire place area reading books chair, grandmother clock, hairdressers, Hollywood and pictures relevant to those peoples on their bedroom doors and bathrooms and toilets had pictures, so that residents can distinguish between different areas and their actual private rooms. These areas are designed so that people with dementia and other specific related issues can walk around the home independent of staff, give stimulation to individuals and just to enjoy the environment. Three residents spoken with felt it gave them enjoyment to see different interesting things to look at and did help them find the different areas of the home more easily. Some people accompany the staff to charity shops to purchase items for the reminiscence cabinet and for the home in general. There is a lift that can take people to the first and second floors to bedrooms. People are provided with plenty of toilets bathrooms and showers on all levels of the home. These areas had adaptations to support people when they were receiving their personal care. All equipment provided by the home such as, hoists, wheelchairs and equipment supplied in bathrooms and toilets were regularly checked for safety and serviced and we saw this by the subsequent documentation looked through. At the back of the house is a large well developed pleasant garden, with plenty of garden furniture, a large shed/conservatory type building. At present there is a path down one side of the garden. The manager told us that she hopes to further develop the garden so that a pathway runs along both sides of the garden to allow people with dementia to use this facility more than they do so and without staff support. Also observation showed that this could be improved in general due to the risk of the pathway being a trip hazard for those residents with mobility issues. This development would enhance people lives further and enable them to be more independent and use the garden more frequently. The deputy also informed us that they would like to develop the raised garden beds into sensory gardens which would further supply stimulation and involve residents within the garden of the home further than they presently do. The home provides full time laundry and domestic staff 7 days a week. We saw that all these staff had undertaken the essential steps of universal infection control training and that there was guidance from the Department of health (a self assessment book) in place which the manager completes on her routine checks of the premises. We saw that the home has a planned schedule of building works and improvement plan that is regularly reviewed at monthly board meetings and discussed with residents, relatives and staff. St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 19 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): 27, 28, 29 and 30 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 cared for by well-supported and caring staff and are protected by staff recruitment, induction and training. EVIDENCE: The manager told us in the Annual Quality Assurance Assessment that all staff were recruited thoroughly, that staff were well trained and that staffing levels meet the needs of all residents. When we visited the home we saw by observation and by looking at the staff rota that there were enough staff to cater for all residents needs. Residents who completed surveys said that staff listen to them and act on what they say. When we visited the home we saw by observation that, staff interact well with residents, were motivated, competent and listened to people. The manager told us that all staff had been at the home for some years. The home provides a staff team which includes manager, deputy, duty officer, senior carers, care assistants, house keeper, domestics, laundry assistant, secretary, gardener, maintenance, chef, cook, kitchen assistant and activities coordinator. By observation and from what residents told us, the team are St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 20 professional, caring and work well together, this provides people with consistency and quality of care. Each shift there are five staff on the day time and evening and three waking night staff during the night. Staff are trained to a high standard and twenty four staff out of the thirty staff employed hold the NVQ 2 or above qualification. Training in general includes, bone health and osteoporosis, Parkinson’s disease. deprivation of liberty safe guards, foot care., tissue viability, optical training ( eye infections, eye diseases) medication, blood pressure, pulse, temperature, fire training, continence and hygiene, blood glucose, dealing with complaints, health and safety, fire, moving and handling, record keeping, medication, safeguarding, risk assessment, challenging behaviour, dementia, diabetes, first aid, food hygiene, palliative care, managing continence, nutrition and many other relevant topics related to residents specific needs. Looking through the ten of the staff files they showed us that all Criminal Records Bureau disclosure and PoVA First checks had been carried out and the people had been interviewed. Once staff commenced work at the home they undertook a period of induction to help familiarise themselves with policies, procedures and the needs of residents. The manager told us that they implemented the Skills for Care Common Induction Standards induction and we saw that this was in place. (This is a set of nationally recognised standards and helps to ensure consistency in the delivery of care and support to people who receive social care.) All seven staff surveys returned told us that they felt, they had up-todate information provided to them regarding the people they care for, had a good thorough induction and covered everything they needed to know before starting the job and that they were given training relevant to their role and that they were updated regularly. Staff spoken with and looking through documentation showed us that regular supervision, yearly appraisals and monthly staff meetings go ahead. Looking through the staff minutes it showed us that topics covered were relevant to the lives of the residents such as, incidents, cleaning, individual residents with current issues and conduct of staff in general and expectations of them. This showed us that the management were good at directing staff, monitoring practice and updating staff on relevant information. St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 21 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): 31,32,33,34,35,36,37 and 38 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 management strategies of the home were stable which ensures the health, safety and welfare of all residents. EVIDENCE: The manager has been in post for six year and holds a RGN, NVQ4 and is an NVQ assessor. She has had twenty seven years experience in nursing and palliative care. The manager works well with CQC and other agencies and continues to let us know about things that have happened since the last key inspection, and she St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 22 has shown us that she has managed issues well. They home works well with us and have shown us that their service continues to provide good outcomes for the people who live there. The manager told us in the Annual Quality Assurance Assessment that there was a system in place for monitoring the quality of the service, including obtaining the views of residents. When we visited the home we looked at the arrangements in place for obtaining the views of the people who live in the home, people who are important to them such as family and advocates and other people who are involved in their care. We saw that people were provided with questionnaires and that residents were asked if they were happy with their surroundings, lifestyles and opportunities available. They were also asked if staff allow them privacy, dignity, independence and choice. The manager has used a quality assurance system called the Pqasso. (Was designed specifically for the voluntary sector, and was introduced in 1997.) This system has assessors that come in monthly to independently assess the management of quality, user views, staff training and development, organisations managing money, activities, networking and partnership with other agencies, then goes onto monitor and evaluate and the results are put into the homes next business/action plan for the following year. The manager told us in the Annual Quality Assurance Assessment that the management are approachable and friendly. When we visited the home three residents told us that the manager works well with them, listens and that their opinions matter to her, the same was reported to us by the surveys returned. Similarly four of the staff on duty felt that she supports them well and feel that she does a good job of managing the home. We looked at how the home was managed and maintained. There were records and certificates to show that the home was maintained and fit for purpose. Checks were carried out to ensure that systems and equipment such as heating and hot water systems, fire detection installations and electrical equipment were maintained in good safe working order, the service has insurance cover for the registered manager’s legal liabilities to employees, people using the service and third parties. We saw reports from the local environmental health officers and these indicated that the manager complied with their regulations. The home had a very thorough accounting system for all residents’ monies and was kept on a computerised system within the home which we sampled. Each year the home is audited independently by contracted accountants. No residents monies are directly looked after by the home and all relatives or social services have this responsibility. We saw that all monies spent in the home was accounted for and receipts kept. (The home employs an administrator to look after this area) St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 23 The manager and her staff carried out fire risk assessments for each person record their understanding action to be taken. Additionally each area (including people’s bedrooms) is risk assessed and we saw that all had a review date which was up to date and signed off. We saw that the Fire safety officer visited July 2009 and the maintenance person carries out daily, weekly, monthly and yearly checks. The trustees come every month and complete regular regulation 26 visits and these were looked at and are kept on the premises. (These visits are to check quality of care in general and to carry out spot checks, including interviewing staff and residents.) St Martins DS0000015469.V377025.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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X 3 X X X 4 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 4 3 4 3 4 3 3 4 St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 OP22 Refer to Standard Good Practice Recommendations That the garden is further developed so that people with dementia can make full use of this area independent of staff and that it would provide extra stimulation for them. St Martins DS0000015469.V377025.R01.S.doc Version 5.2 Page 26 Care Quality Commission Care Quality Commission East Region 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. If you would like a summary in a different format or language please contact our helpline or go to our website. 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. 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