CQC report explained · a residential care home
What the CQC found at St Martins Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, November 2019
Rated Good; inspectors found safe, kind and personalised care across all five areas.
This was an unannounced, planned comprehensive inspection on 11 April 2019. One inspector spoke with three people, three staff members, the manager and the chief executive. They also checked care plans, risk assessments, medicines, recruitment, training and management records.
The home was supporting 26 older people, including some people living with dementia. Inspectors found people felt safe, staff were kind, medicines were managed safely and there were enough staff. People were supported with food, healthcare, communication, activities and choices about their care.
The home was rated Good overall and Good in Safe, Effective, Caring, Responsive and Well-led. This was the same overall rating as the previous inspection on 14 October 2016. The report says legal requirements were met.
People felt safe
People told inspectors they felt safe and supported. Staff understood how to protect people from harm and how to manage risks.
“People told us they felt safe and that staff were kind and caring.” from the report
Kind and respectful care
Staff listened to people, valued their views and supported their dignity, privacy and independence.
“People's privacy and dignity was respected, and their independence encouraged and promoted.” from the report
Safe staffing and medicines
Inspectors found enough staff, suitable recruitment checks and accurate medicines records. Staff giving medicines had training and competency checks.
“People received their medication as prescribed. We found all medication administration charts (MARS) were all up to date and there were no omissions or gaps.” from the report
Personalised support
Staff knew people's needs and used detailed care plans and risk assessments. People were supported to make choices and take part in activities.
“People's care and support needs were well understood by the staff, relatives and people receiving support.” from the report
Positive leadership
Inspectors found a positive, person-centred culture. People, relatives, staff and other professionals were involved and their views were acted on.
“The culture of the service was positive, and person centred” from the report
Inspectors raised no specific concerns in this report.
- 01How would you support my relative's specific needs if they are living with dementia?
- 02How would you involve me and my relative in reviewing the care plan and risk assessments?
- 03What activities and community visits would be available, and how would staffing support them?
- 04How would you support my relative's communication needs if they cannot communicate verbally?
- 05How would you involve us in decisions about end of life care?
This was a planned, unannounced comprehensive inspection covering all five key questions; the previous inspection in October 2016 also rated the service Good. This explanation was written from the published report of 22 November 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2016
Rated Good; inspectors found safe, kind and personalised care, with some minor improvements needed in staff knowledge, meals and pressure mattress checks.
The inspection was unannounced and took place on 14 and 18 October 2016. Inspectors spoke with people living in the home, relatives and staff. They also reviewed care plans, staff records, medicines, complaints and quality checks. There were 26 people living in the home.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines arrangements, suitable care plans and respectful care. People were supported with their health, food, drinks, activities and daily choices.
There were a few areas to improve. One pressure mattress had been set incorrectly, although this was corrected by the second inspection day. Not all staff showed a good understanding of the Mental Capacity Act and related safeguards. Comments about the meals were mixed, although the home had taken steps to improve them.
Safe medicines
Medicines were stored, given and recorded safely. Inspectors checked records for 10 people and found them in good order.
“Medicines were safely stored, recorded and administered in line with current guidance to ensure people received their prescribed medicines to meet their needs.” from the report
Kind and respectful care
Staff were friendly and caring. They respected people's privacy, dignity, choices and independence.
“Our observations demonstrated that staff were friendly, kind and caring towards the people they supported.” from the report
Personalised care
Care plans reflected people's individual needs and were updated when those needs changed. People were supported with activities of their choice.
“Care plans accurately reflected people's care and support needs.” from the report
Quality monitoring
The home used audits, surveys and reviews of incidents and other information to identify risks and make improvements.
“There was an effective system in place to regularly assess and monitor the quality of the service provided.” from the report
Pressure mattress setting
needs fixingOne pressure-relieving mattress was set incorrectly for the person's weight. This was corrected by the second day of the inspection.
“We checked the setting of pressure relieving mattresses that were in place to help prevent pressure ulcers developing or deteriorating further and found that one of these were incorrectly set in relation to the person's weight.” from the report
Mental Capacity Act knowledge
needs fixingNot all staff could explain the Mental Capacity Act and related safeguards well enough. The management team said further training would be provided.
“Although the majority of staff confirmed they had received Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) training, not all staff were able to demonstrate a good knowledge and understanding of MCA and DoLS and when these should be applied.” from the report
Mixed views about meals
minorPeople's views about the meals were not all positive. The home had introduced a new meal provider and was continuing to address the issues raised.
“Comments about the quality of the meals were variable.” from the report
- 01What further training have staff completed on the Mental Capacity Act and Deprivation of Liberty Safeguards?
- 02How do you check that pressure-relieving mattresses are set correctly for each person?
- 03What changes have been made to meals since people gave mixed feedback at this inspection?
- 04How are changes in a person's care needs passed on to all staff and recorded in their care plan?
- 05What improvements have resulted from recent surveys and residents' meetings?
This was an unannounced inspection of all five key areas, based on discussions with people, relatives and staff, observations and reviews of care, medicines and management records. This explanation was written from the published report of 8 November 2016 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of St Martins Residential Home
3 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- November 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- June 2012
Registered with the Care Quality Commission on 15 June 2012.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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