St Martins Residential Home

Updated 3 May 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 2 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.

Service and service type

St Martins Residential Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. St Martins Residential Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 3 members of staff and the registered manager. We reviewed a range of records. This included 2 people’s care records and multiple medication records. We looked at 4 files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed. After the inspection we continued to seek clarification from the provider to validate evidence found and the provider was able to provide evidence of actions taken following the inspection.

Updated 3 May 2023

About the service

St Martins Residential Home is a care home providing accommodation and personal and care to 16 people with mental health needs. At the time of the inspection there were 13 people living in the home.

People’s experience of using this service and what we found

Risks in relation to people's care had not been effectively assessed and medicines were not always managed safely. There was a lack of understanding around the Mental Capacity Act 2005 and, it's application. The provider did not show the appropriate knowledge around their responsibilities in relation to finance and consent. The systems in place to monitor the quality and safety of the service were not always used effectively to identify and mitigate risks. We have made a recommendation regarding recruitment.

People were not supported to have maximum choice and control of their lives. Staff supported them in the least restrictive way possible and in their best interests; however, the policies and systems in the service did not support this practice.

The registered manager had improved the environment and the safety checks where up to date however we identified additional fire safety improvements were required.

Staff received regular training, supervisions and attended staff meetings and there were enough staff on duty on the day of inspection to meet people's needs. Referrals were made to other professionals in a timely when people living in the home were in need.

Feedback we received from staff, people and relatives was positive in regard to the registered manager. We observed support being provided in the home and saw this was done in a caring, responsive, and patient manner. We saw people were comfortable in the presence of staff and positive relationships had developed between people receiving support and staff.

People were consulted with in the form of residents meeting s and quality assurance questionnaires. There was evidence of how the registered manager acted on people’s opinions.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 20 May 2021). The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

The inspection was prompted in part due to concerns received about fire safety. A decision was made for us to inspect and examine those risks. We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Martins Residential Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to risk management, consent and governance at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.