CQC report explained · a residential care home
What the CQC found at The Martins
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm and there were enough staff observed on the inspection day. However, inspectors found gaps in weight monitoring, medicine records, some PRN protocols, safeguarding escalation knowledge and staff induction training.
- Effective?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Caring?
- Outstanding
- This key question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- Care plans were individualised and reflected people's needs, preferences and communication methods. People were offered activities and support to maintain relationships, and complaints were dealt with in a timely way.
- Well-led?
- Good
- The management team was described as open, approachable and person-centred. Audits and investigations were in place, but the audit system had not identified some medicine and weight-recording shortfalls, and CQC notifications had not always been submitted on time.
What inspectors found, October 2022
Rated Good; inspectors found kind, person-centred care, but medicines and some records needed improvement, and the rating fell from Outstanding.
This was an unannounced focused inspection on 13 September 2022. Inspectors spoke with eight people, four relatives and seven staff. They reviewed four care records, medicines records, four staff files and other safety and quality records.
The home was rated Good overall, with Safe, Responsive and Well-led also rated Good. Inspectors found enough staff on the day, safe recruitment, good infection control and care plans that reflected people's needs and preferences. People and relatives described staff as kind and supportive, and said communication was good.
There were some shortfalls. Records of weekly weights were incomplete, some medicines records were not properly completed, and not everyone had a suitable protocol for occasional medicines. The home also needed to improve some staff induction training and ensure significant events were reported to CQC on time.
The rating changed from Outstanding at the last inspection, published in 2017, to Good. This inspection only looked at Safe, Responsive and Well-led. The ratings for Effective and Caring were not inspected and were carried over from the previous inspection.
Kind relationships
Inspectors saw respectful interactions and meaningful relationships between staff and people. Relatives spoke positively about the caring culture.
“Staff supported people in a caring and respectful manner. Interactions demonstrated that staff and people had developed meaningful relationships.” from the report
Personalised care
Care plans included people's needs, preferences, life histories and interests. People and relatives were involved in developing and reviewing them.
“People's care plans were individualised and person-centred.” from the report
Activities and contact
The home provided a range of activities, including one-to-one support for people cared for in bed. It also helped people keep in touch with friends and relatives.
“People were supported to undertake a range of activities that met their needs and preferences.” from the report
Open management
The management team was described as approachable and open about problems. Incidents were investigated and actions were taken where needed.
“The registered manager had an open and honest approach including in their response when things went wrong.” from the report
Incomplete weight records
needs fixingSome people at risk of losing weight did not have complete weekly weight records. The manager said immediate action had been taken.
“Where people had been identified at risk and required weekly weight monitoring, we found gaps in staff recording of these.” from the report
Medicine records and protocols
needs fixingCarry-forward medicines were not recorded on some medicines administration records, and not everyone had a protocol for occasional medicines. The shortfalls were addressed promptly during the inspection.
“We found carry forward medicines from the previous month had not been recorded on Medicines Administration Records [MAR].” from the report
Staff training records
needs fixingThere were gaps in the system for checking that staff completed all training required during induction. The manager said plans were in place to improve this.
“We found gaps in the system for ensuring staff received all training required as part of their induction.” from the report
Late CQC notifications
needs fixingThe manager said notifications of deaths had recently fallen behind the legally required timescales. Management processes were reviewed in response.
“The registered manager confirmed they had recently been behind in completing their notifications of death to CQC as is required by law.” from the report
- 01What checks now make sure weekly weights are recorded for everyone at risk of losing weight?
- 02How do you check that all medicines are correctly recorded, including carry-forward medicines?
- 03Does every person who may need occasional medicine have an up-to-date PRN protocol?
- 04How do you make sure new staff complete all required induction training before working alone?
- 05What changes have been made to ensure deaths and other significant events are reported to CQC within the required timescales?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were used in the overall rating. This explanation was written from the published report of 13 October 2022 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, January 2022
Inspected but not rated; inspectors found comprehensive COVID-19 infection prevention arrangements.
This was an announced, targeted inspection on 13 January 2022. Inspectors looked at infection prevention and control, and asked about staffing pressures linked to COVID-19.
Inspectors found regular testing, visitor screening, vaccination checks, good supplies of personal protective equipment and hand sanitiser, and regular cleaning. Staff had updated infection control and PPE training.
The home supported residents and relatives to keep in contact, including through weekly Zoom calls. The service was inspected but not rated, so this report does not give an overall quality rating.
Infection control planning
The home had detailed policies for managing COVID-19 risks, including for people who tested positive.
“The service had comprehensive policies and procedures to manage any risks associated with the COVID-19 pandemic.” from the report
Testing and visitor checks
Residents, staff and visitors were tested regularly. Visitors were screened and had to show vaccination evidence and a negative lateral flow test before entry.
“There was a system of regular COVID-19 testing for both people who used the service, staff, and visitors.” from the report
PPE and cleaning
There was plenty of PPE and hand sanitiser. Staff had updated training and regular touch-point cleaning was carried out.
“There was a plentiful supply of personal protective equipment [PPE] for staff and any visitors to use.” from the report
Keeping families connected
The home helped residents and relatives maintain contact and offered weekly online calls with updates about changing COVID-19 guidance.
“The registered manager offered weekly Zoom calls to friends and relatives of people who used the service to provide information and updates” from the report
Inspectors raised no specific concerns in this report.
- 01How have your COVID-19 testing, visitor screening and PPE arrangements changed since the inspection on 13 January 2022?
- 02How do you manage staffing pressures linked to COVID-19, and how could these affect residents' care?
- 03How do you check that staff and visiting professionals meet current vaccination or exemption requirements?
- 04How will you support visits and contact with relatives if there is an outbreak?
- 05How often are touch points and other areas cleaned, and who checks that this is done?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; it did not provide ratings for the other key questions. This explanation was written from the published report of 27 January 2022 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 The Martins
3 rated inspections over 8 years: the service has held its Good rating throughout.
- October 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- January 2022Inspected but not ratedSafe: Inspected but not rated
- September 2017Outstandingup from GoodSafe: GoodResponsive: OutstandingWell-led: Outstanding
- February 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 22 December 2010.
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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23 live-in carers within about an hour of Suffolk
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Most charge £1,020 to £1,260 a week. 17 can care for a couple. 7 years' experience on average.
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