8 and 13 January 2015
During a routine inspection
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.