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Inspection Summary

Overall summary & rating

Requires improvement

Updated 15 November 2018

This inspection took place on 15 and 16 August 2018 and was unannounced.

St Martins is a ‘care home.’ People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and care provided, and both were looked at during the inspection. St Martins accommodates up to 30 people in one adapted building. The building is an older building providing large communal areas. At this inspection, 23 people were living at the service. People who used the service were older people with a range of care needs including diabetes, dementia and reduced mobility.

The registered manager worked at the service each day and was supported by a deputy manager. A registered manager is a person who has registered with CQC to manage the service. Like registered providers they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We last inspected St Martins in March 2017. This was a focussed inspection, looking only at the key area of ‘Effective’, which was rated as ‘Requires Improvement’. This was because the registered manager and staff had limited knowledge of their responsibilities about the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). At that inspection, the required improvement was made and the service received a rating of ‘Good’. The last comprehensive inspection was completed in October 2016. At that inspection, except for ‘Effective’, the service received a rating of ‘Good’ for each key area as well as an overall rating of ‘Good’.

People and their visitors told us were happy with the care and quality of service provided. However, at this inspection there were three breaches of regulation and two other areas identified that required improvement. This is the first time the service has been rated Requires Improvement.

Medicines were not always managed safely, PRN protocols for medicines to be taken as and when needed required updating, there was no guidance to distinguish medicines that needed to be taken at times outside of the usual medication rounds, medicines to be returned to the pharmacy were not handled in line with the service’s policy and skin creams were kept insecurely in people’s bedrooms. Storage of creams in people’s rooms had not been risk assessed and the temperature at which the creams were kept was not monitored as required.

The building was adapted to meet people’s needs. Staff completed checks on the environment and equipment, these helped to ensure people were safe. However, the safety certificate for the fixed electrical wiring at the service had expired and there was no record whether electrical work noted as requiring urgent remedial attention had been addressed.

A complaints procedure was in place and was under review to include pictorial prompts to make it easier for some people to use. However, we found a complaint received had not been recorded in line with the service’s policy.

Services that provide health and social care to people are required to inform CQC of important events that happen in the service. This is so we can check that appropriate action had been taken. The manager was aware that they needed to inform CQC of important events in a timely manner, however, they had not always done so.

Staff were recruited safely, however, some decisions about the employment of staff, although considered, were not always recorded. This is an area identified for improvement.

Pre-assessments for people moving to the service were comprehensive. Potential risks to people’s health and welfare were identified, however although staff were knowledgeable about people’s conditions, there was not always guidance for them to refer to. This is an area identified for improvement.

Staff knew how to recognise the signs of abuse and knew how to report any concerns they may have.

Inspection areas


Requires improvement

Updated 15 November 2018

The service was not safe.

Medicines were not always managed safely and records of returned medicines were incomplete.

Environment, equipment and fire safety checks had been regularly undertaken, however, an electrical safety certificate was out of date and there was no evidence urgent remedial work to electrical wiring was completed.

There were sufficient staff to meet people’s needs, however, some processes around their recruitment needed to be improved.

Accidents and incidents were recorded and investigated; learning took place to reduce risks of future occurrences.

People were protected from abuse and discrimination.

People were protected from the risk of infection.



Updated 15 November 2018

The service was effective.

Staff had received training and support to enable them to carry out their roles effectively.

People's health was monitored and staff ensured people had access to external healthcare professionals when they needed it.

Staff understood the importance of gaining consent and giving people choice.

People were provided with a range of nutritious foods and drinks.

The premises were designed and decorated to meet people’s needs and wishes.



Updated 15 November 2018

The service was caring.

Staff took the time needed to communicate with people and included people in conversations.

Staff spoke with people in a caring, dignified and compassionate way.

Staff supported people to maintain contact with their family.

People were treated with kindness, respect and dignity.


Requires improvement

Updated 15 November 2018

The service was not consistently responsive.

There was a complaints system and people knew how to complain, however a complaints process was not displayed and a complaint had not been dealt with in line with the services policy.

People's care and support was planned in line with their individual care and support needs.

Staff had a good understanding of people's needs and preferences.

People were supported to take part in activities that they chose.

The service was not supporting anyone at the end of their life. Care plans included information about people’s known wishes.


Requires improvement

Updated 15 November 2018

The service was not well-led.

Regular audits and checks did not ensure the service was safe and running effectively.

There was a registered manager. Although, they understood their regulatory responsibility, they had not submitted all statutory notifications as needed.

People, their relatives and staff were positive about the registered manager. Staff felt they were approachable.

The service demonstrated a learning culture with staff given opportunity for progression and professional development.

The service worked effectively in partnership with other organisations and agencies.