St Martin's Residential and Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Accidents and incidents were recorded and reviewed by management. Referrals were made, if necessary, to external healthcare professionals or changes made to people’s care. Lessons learnt were shared with staff through meetings and supervisions.

The management team held monthly meetings with managers from the organisations other services to share good practice and learn from incidents.

Daily meetings took place to discuss people's needs. Any changes or incidents that may have occurred were discussed to ensure all staff were up to date.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care.

Staff knew and demonstrated a good understanding of people's needs. Health and social care professionals were contacted in a timely manner when required to offer support and guidance.

People with a high level of need were supported on a one-to-one basis to remain safe. This was discussed at length with family members.

People, their relatives, and other professionals were involved in planning people’s care and support needs. Multi-disciplinary meetings were held to discuss safe care and treatment pathways for people, and staff knew when to refer to specialist services to support and manage people’s care safely.

A healthcare professional told us “Clinical and safety processes are followed meticulously, and their collaboration [with healthcare professionals] goes above and beyond expectations, fostering a level of trust and professionalism”.

The provider worked with people and healthcare partners to understand what being safe meant to them and how to achieve that. Concerns were acted upon however they did not always share concerns quickly and appropriately.

People told us they could raise concerns to staff and the registered manager and were confident actions would be taken.

One relative described a recent incident where the registered manager had acted immediately to reduce risk and kept the person informed of the investigation. However, this incident had not been reported to the local authority or the CQC at the time of the event. Following the inspection the registered manager submitted a safeguarding alert.

The provider ensured staff received safeguarding training to recognise signs of abuse and how to escalate concerns. The registered manager had not completed training for their additional responsibilities as a manager. For example, the need to raise a safeguarding alert to the local authority in a timely manner following any safeguarding concerns. We discussed this with the registered manager who told us additional training for the registered manager would be arranged.

The registered manager and staff ensured any restrictions imposed to keep people safe, such as the use of bed rails, were in people’s best interest and the least restrictive option available. Deprivation of Liberty Safeguards (DoLS) applications had been made to the local authority for authorisation.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care records informed staff about risks associated with people’s health and wellbeing and the action they needed to take to mitigate identified risks. For example, 1 person’s care records included recommendations made by a health care professional to manage the risk associated with having a seizure. Records confirmed staff had followed the recommendations.

Care records and risk management plans had been regularly reviewed and updated where needed.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider had clear plans to support the safe evacuation of people in the event of an emergency. Fire drills were undertaken with all staff to ensure they had the practical skills and equipment needed to safely evacuate people in the event of a fire.

The environment was visibly clean, tidy and warm. Records showed health and safety checks were carried out frequently. Care equipment, such as moving and handling aids were serviced and maintenance records kept.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service was well staffed, and rotas showed planned staffing levels were routinely achieved. Staff told us, “We have enough staff, if someone goes off sick the deputy does cover” and “Agency staff are used to provide one-to-one support”. The registered manager told us that they had 1 vacancy which was covered by an agency nurse. The same agency staff worked regularly in the service to ensure consistency.

A healthcare professional stated “Staff are always visible, engaged, and attentive. Every area is appropriately staffed, and residents who remain in their rooms are still actively included and supported”.

People stated that where people remained in their rooms throughout the day, all the staff including housekeepers, carers and nurses regularly “popped in” to ensure the person was comfortable and to speak with them. One relative told us “They couldn’t do more for [my relative]”.

Staff received support through formal and informal face to face meetings with their line manager. This gave them the opportunity to discuss their role, concerns and training needs as well as personal welfare. Staff told us they felt supported and that there was a “nice team”.

Prospective staff went through a safe recruitment process which included their right to work in the UK and their fitness for the role. All staff had undergone a Disclosure and Barring Service (DBS) check to help ensure they were suitable to work in the care sector.

All staff completed training relevant to their role and 1 member of staff told us they had been offered additional training.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff did not always follow the providers infection control policy; however, this was addressed in a timely manner.

Infection control audits were completed monthly and effectively identified potential risks. A recent audit had identified ripped dining chairs, which would be difficult to clean and needed to be replaced. One person had a recliner chair that was damaged and difficult to clean. Staff had taken action in response to the audit and a referral for a new chair was made promptly.

Staff had completed infection prevention and control training. Personal protective equipment (PPE) was available throughout the service.

Staff did not always adhere to the provider’s infection prevention and control policy and procedure. For example, we observed 1 member of staff carrying an open bag containing soiled laundry without wearing gloves and an apron. We spoke with the registered manager who told us they would address this immediately. The provider’s policy stated PPE should be worn when there is a risk of exposure to contaminated items.

The laundry room was clean and well organised. Housekeeping records showed daily and weekly cleaning schedules for all areas in the home, had been completed.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Peoples’ care needs and the signs and symptoms people required medication were known by staff, however this was not always reflected in the information recorded.

The provider had medicines policies and procedures and had invested in an electronic medicines system which had recently been implemented.

Medicines were stored securely and staff monitored temperatures of areas used to store medicines, to ensure they were kept within the recommended range. Medicines were managed by staff who had received training and had their competency assessed.

People’s medicines were regularly reviewed and care plans contained detailed information to support staff to meet people’s needs. Protocols for ‘as required’ medicines had been developed; these were reviewed monthly and usually contained detailed information to support staff. However, there was not enough detailed information on how staff should support people if they became agitated and distressed. We discussed this with a staff member who described how and when medication should be given during periods of distress and this aligned to the care plan.

Medicine audits were completed and any discrepancies acted upon. Medicines that required additional storage security, such as controlled drugs, were audited twice a day by nurses, however the weekly audit completed by the management team had not been consistently completed. The registered manager was aware of this and stated this would be completed.