Archived: St Martha's Limited

Updated 15 May 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place over two days. The first visit was on 8 January 2015 and was unannounced which meant the provider and staff did not know we were coming. Another visit was made on 13 January 2015 which was announced.

On 8 January 2015 the inspection team consisted of three adult social care inspectors and an expert by experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. On the 13 January 2015 the inspection team consisted of three adult social care inspectors.

Before the inspection, we reviewed the information we held about the service, including the notifications we had received from the provider. Notifications are changes, events or incidents the provider is legally obliged to send us within required timescales. We gathered information from Sunderland Council Safeguarding, Sunderland Council Commissioners, Sunderland CCG and Sunderland Healthwatch.

During this inspection we spoke with 14 people who lived at the home, five relatives, five care staff, one senior care assistant, three managers and the registered provider.

We carried out an observation using the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We undertook general observations of how staff interacted with people as they went about their work.

We looked at four people’s care plans and 18 resident’s medicines records. We examined six staff files including recruitment, supervision and training records. We also looked at other records relating to the management of the home.

Updated 15 May 2015

This inspection took place over two days. The first visit on the 8 January 2015 was unannounced which meant the provider and staff did not know we were coming. The second visit on 13 January 2015 was announced.

St Martha’s Limited is registered to provide accommodation and personal care for up to 24 older people, including some people who were living with dementia. At the time of our inspections they were 18 people using the service.

St Martha's Limited is located in a large Victorian building that has been converted to its present use. The home is located over two floors and has 24 single bedrooms, three large lounges, two dining rooms and a terrace. There is also a garden that is accessible for people who live at the home.

We last inspected the home in November 2013. At that inspection we found the service was meeting all the essential standards that we inspected.

As the provider is registered as an individual there is no requirement for a registered manager to be in post. A registered manager is a person who has registered with the Care Quality Commission 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.

People told us they felt safe. We found people’s medicines were not managed or administered safely. We also found the provider had not undertaken the necessary recruitment checks to ensure staff were suitable to work with vulnerable people.

We found the registered person did not have an effective system in place to ensure staff received receiving appropriate training and development.

We observed at lunchtime the dining room was nicely set with tablecloths, and a vase with flowers. People told us their meals were good, with adequate portions.

People were supported by sufficient numbers of staff. We saw all staff were very professional and had a patient and caring attitude that treated people as individuals with dignity and respect.

When relatives arrived they were given a friendly greeting. Relatives told us “We can visit anytime and we are made welcome”.

Care plans were not reviewed regularly and did not reflect people’s changing needs. This meant staff did not have access to up to date information about how people should be supported and cared for.

People and relatives told us they knew who to go to if they had any concerns. One family member said, “I would go to the manager if I needed to”.

We observed people taking part in various activities. We saw photographs of outings people had taken part in and of a recent candlelight dinner held for people. One person told us, “We had a lovely night and a good laugh”.

We found the provider did not have a formal system in place to monitor the quality and safety of the service provided in carrying on the regulated activity.

We asked the manager about the requirement to make safeguarding notifications to the CQC. The manager told us she was not aware of this requirement. We are dealing with this matter outside of the inspection process.

We cannot confirm that the service gathers information about the quality of their service from a variety of sources. The manager did not have regular procedure in place for gathering the views and comments about the quality of the service provided at the home from people using the service, their relatives, visitors or stakeholders.

Staff did not have structured opportunities to share information and give their views about people’s care.

During our inspection we identified six breaches of regulation. You can see what action we told the provider to take at the back of the full version of the report.