St Martins Care Home Ltd

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 avoidable harm. At our last inspection this location was rated as good overall, requires improvement in the key question safe. At this assessment we found significant concerns. The provider had failed to ensure the environment and premises used by people were safe which resulted in a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were exposed to significant risk of harm due to the poor environment conditions they lived in. People were at risk of scalding due to unsafe water temperatures. The provider could not be assured people would not be harmed from this. People were exposed to significant risk of infections. The lack of hot water meant people and staff were not able to maintain good hygiene practices and infection prevention. The provider could also not be assured they were not exposing people and staff to the risk of legionella disease, as the water temperatures in the hot water tanks were not to the safe consistent temperatures. There was a strong malodour in one person’s bedroom, which meant this was inhabitable and the person had to source alternative accommodation. Pest control had visited three times, however the malodour remained. We found the provider had sourced plug-in air fresheners for the person’s room. However, this was only an attempt to mask the malodour, which was also ineffective. People were exposed to significant risk of harm in the event of a fire. There were issues with the electrics for the home, which meant the electrics kept going off and the provider had advised staff to speak with their electrical engineer as to how to re-set the fuse box. The provider could not be assured that in the event of a further power, the fire alarm systems would alert staff in a timely manner.

The heating and hot water stopped working on 30 March 2024. The provider told us they had contacted their electrician to visit to resolve the electrical concerns, however they could not get their heating engineer in until the weekend of 6 April 2024. We wrote to the provider on 5 April to seek assurances people would have access to safe hot water and heating. The provider confirmed to us this would be done by 8 April 2024. However, on our return visit on 8 April, we found people continued to be without heating and hot water. Staff told us the provider had been consistently told over the years by their heating engineers that a new boiler heating system was required, but this work had not been carried out. The provider told us it was a big job, which would be done in the warmer months, when people did not need central heating. Staff understood how the environment might pose risks to people and reported their concerns about the environment to the provider but felt the provider did not act promptly or sufficiently to address their concerns. One staff member told us, “[The provider] just puts a sticking plaster on things and doesn’t fix it properly.” For example, staff raised concerns about potential trip hazards for people, where the flooring was ripped, or thresholds between doorways had not been put in which meant the carpet was frayed, and floor heights were not level.

The environment of the home was inadequate. It was clear the lack of adequate consistent maintenance exposed people to significant risk of harm and compromised people’s dignity and did not show respect for those who lived and worked there. Most bedrooms and communal bathrooms did not have hot running water. For outlets where there was running hot water, our recording of these showed they were above safe temperatures levels required to minimise the risk of scalding. Hot water temperatures were not being monitored by the provider. Portable heaters were in use in bedrooms and communal areas. The provider failed to risk assess these, to ensure they were safe for use in all areas. For example, some people had reduced sight, while other people walked independently with walking aids, so there was an increased risk of trips, falls and burns. Room temperatures were not monitored, to ensure these remained at a comfortable temperature for people. We found fire doors to people’s bedrooms, kitchen and laundry room did not close properly which placed people at increased risk of harm in the event of a fire. We found some radiator covers were damaged, some were not attached to the wall, and 2 radiator covers were covered with a fabric. Not having appropriate radiator covers meant people could be at risk of severe burns if they were to come into contact with it. While the provider had pest control out on three occasions, we could smell a strong malodour in one person’s bedroom which meant it had continued to be inhabitable for the person. We found there was only one shower room available for 15 people, the second bathroom had been out of commission for a long time. One staff member said, “I have only known of one time the bath was in use in all the years I have worked here.” Staff explained the bath could not be used, as people could not access it, as there was no chair to support people into the bath. We identified a number of areas of flooring which posed a potential risk hazard.

Risks to people’s health, welfare and safety had not been adequately assessed, managed and mitigated. Where the registered manager had reported monthly to the provider the shortfalls and failings in the environmental aspects, the provider did not assess these risks or take adequate action to mitigate and manage identified risks to ensure people were safe. People were not safeguarded from potential avoidable harm.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.