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Archived: St Martins Residential Care Limited

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Inspection report

Date of Inspection: 14 September 2011
Date of Publication: 4 November 2011
Inspection Report published 4 November 2011 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Not met this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

Our judgement

We found St Martins was not meeting this essential standard and improvements are required.

Overall we found that outcomes for people using the service were positive. However, we have minor concerns in regard to this outcome and the lack of appropriate systems for gathering, recording and evaluating accurate information about the quality and safety of the care and support the service provides, and how outcomes for people can be maintained or improved where required.

User experience

Most people living at St Martins have varying levels of dementia and different communication needs. We were therefore unable to fully understand people’s specific issues.

Other evidence

Staff with whom we spoke all told us that the manager was approachable, transparent and “very hands on.” One staff member told us that “people in the home feel the manager’s presence and really miss her when she is not here.”

The manager told us that resident meetings were not held as often as they used to be as people currently using the service were no longer able to participate in group meetings. The manager also told us that relative meetings and coffee mornings had been promoted but these were not well attended.

The last quality monitoring survey for residents, relatives and other stakeholders was undertaken in 2009. A survey was not undertaken in 2010. The manager told us that a survey was planned for the autumn 2011.

During our visit we found that there were no formal systems in place to audit the performance of the home and outcomes for people using the service, such as medication administration, care planning, accidents, health and safety, hygiene and infection control. The manager told us that some reviews were undertaken such as checking medication administration records and health and safety but outcomes were not recorded or evaluated to inform an improvement plan. Such audits would inform quality monitoring and identify any non compliance, or potential non compliance with regulations or how outcomes can be improved for people using the service.

For example the accident records showed a high incidence of falls. We found that some records did not accurately stipulate whether the time of the fall was during the day or the night so it was difficult to identify an overview of any trends. There was no evidence to show that incident/accident records had been analysed and evaluated to identify any themes or trends with people’s falls and how the risk may be reduced or minimised.