Inspection on 10/01/07 for Marmora Residential Home

This inspection was carried out on 10th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Marmora Residential Home 08/07/09

Marmora Residential Home 17/07/07

Marmora Residential Home 30/05/06

Marmora Residential Home 10/02/06

Marmora Residential Home 24/03/05

Marmora Residential Home 26/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Marmora Residential Home 4/6 Penfold Road Clacton On Sea Essex CO15 1JN Lead Inspector Sara Naylor-Wild Key Unannounced Inspection 10th January 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marmora Residential Home Address 4/6 Penfold Road Clacton On Sea Essex CO15 1JN Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01255 422719 01255 423830 Salsar Ltd Manager post vacant Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 27 persons) 30th May 2006 Date of last inspection Brief Description of the Service: Marmora is a care home for older people accommodating a maximum of 27 service users. The building is of an older style, with two lounges on the ground floor and bedroom accommodation that, with the exception of two double rooms, is made up of single rooms provided on three floors, with lift access to all bedroom accommodation. The property is detached and situated within walking distance of all local amenities within Clacton town centre. The home is in close proximity to the sea front at Clacton. The home has a garden area to the rear of the building and parking is available at the front aspect. The range of fees charged by the home is between £358 and £420 per week. Additional charges are made for hairdressing, chiropody, newspapers, external activities and staff escorting to health care visits. This information was provided to the Commission in April 2006. Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second key unannounced inspection of the service, and it took place on 10th January 2007. The lead inspector was joined for the purposes of these visits by Lysette Butler, Regulation Inspector. Information used to inform this report includes the providers reports and preinspection questionnaire, discussions with residents, visitors, staff and the management team and examination of documents such as assessments, care plans and staff records. What the service does well: What has improved since the last inspection? What they could do better: The information gathered from residents’ assessments and reviews must be consistently sought and used to update the care plans. Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 6 Care plans should reflect all the knowledge held in respect of residents’ strengths, needs and aspirations. The staff skills in providing residents with opportunities to participate in activities throughout their daily lives need developing and encouraging. The use of lounges and provision of televisions requires some consideration. The range of staff training requires greater breadth of subjects to ensure that staff are skilled in meeting the assessed needs of residents. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents benefit from an improving quality of assessment of their needs. However residents cannot always be assured that the quality of the information in assessments is consistent. EVIDENCE: The resident’s files contained individual contracts or terms and conditions with the service and an example was also contained in the Service users guide provided to prospective residents. The contract contained reference to the elements set out in the Care Homes Regulations 2001 and the NMS (National Minimum Standards) for older people. Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 9 The service collects information about the resident’s needs in a number of ways prior to their entering the home. First where a resident is referred by social service, a Social Workers assessment is provided to indicate why the individual requires 24 hour care, the service then sends a member of staff to visit the prospective resident to carry out their own initial assessment, as part of this they speak to professionals involved with the person including where appropriate hospital staff. Finally, when the individual has been admitted to the home, they add to the initial assessment over a period of 28 days to build a picture of the individual and how they require support. Resident’s files sampled contained details of these assessments and in considering the initial assessments that had been made prior to the resident moving to the home. Inspectors found that in some cases the quality of information held on them varied according to how much of the form had been completed. In the best cases the member of staff completing these had ensured that supporting information had been provided to give the fullest picture of the impact of the identified need. So for example where the individuals mobility required assistance they had indicated to what level this should be supported. The inspectors acknowledge that although information is added during the 28 days of the in house assessment process, this initial assessment is the point at which the service determines its ability to meet the individuals needs and ensure that equipment and resources are available. Therefore the more information given the more opportunity there is to ensure a successful and appropriate admission process. Examples of this were discussed with the persons in charge of the service on the day and good practice recommendations made in relation to developing the outcomes. There is no intermediate care provided in the service. Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from care plans that are a better reflection of their needs and how staff should best support them. The care plans are improved but require monitoring to ensure they contain all the information gathered about the individual and provide the full benefits to staff in providing care. Attention is required to ensure Medication storage meets the good practice guidance. EVIDENCE: Five care plans were reviewed during the site visit. There was a wide range of information included in all the care plans reviewed, however there were also a Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 11 number of areas that were under utilised. In some cases where information was held in the assessment forms this had not been transferred to the care plan and its significance therefore was missed when staff addressed care needs. This included the documented depressive state of a resident’s mental health, the need to address a poor appetite and concerns over weight loss for another resident and significant relationships for other residents was not acknowledged. Whilst staff may be aware in their working day of these issues, by not including them in the care plan, corresponding monitoring tools are not created to determine how successfully these were addressed. However, overall there has been a marked improvement in the care plans and the management view was that they should be the basis of care offered by all staff including agency and new staff. Although it was obvious that the care plans were the basis for care, in the opinion of the inspectors there was still some way to go before they were sufficient to stand on their own. Most of the care plans reviewed had been signed and agreed by the residents’ relatives even in the case of two residents who had the mental capacity to sign their own plans. The inspectors felt that this was more about confidence to progress care plans rather than deliberately ignoring the residents’ views. The health care needs of residents were noted and there was evidence that residents were offered appropriate regular health checks both within and outside the home. However documentation of changes to care offered was minimal and although both district nurse and GP visits were documented, there was not detail of what changes were made or what advice was given. The inspectors found that there was a lack of risk assessments particularly around skin integrity. On discussion with the management team of the home it was ascertained that the visiting district nurses undertook risk assessments, such as Waterlow scoring. Whilst the care home staff may carry out visual checks of residents skin in the course of providing personal care, there is not a mechanism for the baseline assessment of all residents skin health carried out in the home. If the assessment is undertaken for all residents the service ensures that they are proactive in making appropriate referrals are to protect skin integrity not just at the point where there are visual signs of breakdown. This home uses the Nomad system to administer the residents’ medication, which is delivered weekly from the dispensing pharmacist. The medication trolley is kept locked to the wall with extra medications kept in a securely locked drawer. The trolley was clean and tidy when inspected. There is a dedicated medications fridge, which only contains appropriate medications. Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 12 Neither the room that the medications are stored in, nor the medications fridge are regularly checked for temperature levels. The inspectors discussed with the management team the importance of taking and recording the temperatures on a regular basis to ensure that the medications are stored in accordance with Royal Pharmaceutical guidelines. This home does not keep homely remedies and contacts the resident’s GP if extra medication is required. All medication administration records were reviewed during this visit and no omissions were noted. The front sheet of each record contained a picture of the resident, however the picture’s were not dated and so it was recommended to the head of care that these be dated in future so that staff can be aware how recent the image was. At the time of the site visit only one resident was self-medicating. All residents are asked on admission if they wanted to self-medicate, however there was no documentation to back this information up and risk assessments had not been carried out on all admissions as a baseline observation. On discussion with the head of care they was clear that the home uses a risk assessment that had been suggested following the last inspection and that anybody that chose to self-medicate would be assessed to administer their own medications for a minimum of a week on admission, or longer if they or the staff felt it necessary. There was very little overstocking of medication however there is still an ongoing problem with one particular item of medication that was being sent by the pharmacy weekly although there was no need for it to be dispensed weekly. Weekly medications, which had to be given in a particular way, are now only administered by two of the staff to ensure that all directions are followed correctly. Throughout the site visit the inspectors observed all residents being treated with respect and dignity. Although the service should consider how it demonstrates respect and dignity in all areas of care provision such as person cantered planning and activities. Privacy appeared to be maintained throughout the home by all staff. Residents spoken with said that staff were “ extremely kind and are all really careful to keep me covered and keep doors closed as appropriate.” All residents spoken with stated that staff now seemed to be working very closely as a team which had a number of benefits for the residents particularly with regard to the respect they were shown and the privacy they were offered. Another resident said that staff were all “ lovely and gave as little or as much Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 13 help as we ask for.” One relative spoken with felt that their relative was very well looked after both physically and emotionally and stated that their relative was always in clean well laundered clothes, and that staff were very helpful. “ We are all so looked after very well when we visit and staff couldnt be kinder.” This home has a very good detailed form regarding the residents’ wishes should they become terminally ill or die in the home, which is kept in the care plan. However it was not used or completed in all of the plans reviewed. Those that had been completed ensured that the staff had enough information to care for both the residents and their relatives at the end of the residents’ life. Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents enjoy an improved opportunity to participate in activities and freedom to make choices in how they spend their day. However, staffs understanding of the skills required to encourage residents’ participation in daily activity and occupation needs development to ensure all residents benefit from the activities on offer. EVIDENCE: Residents spoken to stated that there has been an increase in the number and types of activities offered within the home. A number of residents mentioned that care staff offered more one-to-one sessions so that they could chat or take part in activities they enjoyed, however the residents also said that they didnt like to ask staff to sit down with them on a one-to-one basis to often as “they are always so busy”. From discussions with staff and residents it was evident that there was a good organised activity programme and staff were Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 15 identifying those residents that enjoyed board games etc in care planning and daily activity planning. Current good practice guidance in the provision of activities to older people identifies that whilst organised activities are a basis for the stimulation and occupation of residents there should also be an engagement of residents in routine daily tasks. This requires staff to change their approach to undertaking their work with and around residents to incorporate them into the tasks. From reading daily records, observations of staff and resident interaction and discussions with staff and residents the inspectors identified that this was an area of development in the service. One resident spoken to told the inspector that staff were very careful to give them choice in their everyday life. “ I go to bed and get up when I want; I can have what I want to eat; and although there are a number of activities offered I dont wish to join in and staff respect this.” The resident was generally very happy in the home and felt there had been a great improvement in the atmosphere of the home over the previous few months, particularly in the way staff work together as a team. Other residents spoken with also talked about the way staff work as a team and that they have choice in their day-to-day life. Two residents that live at the home said that they tried to get out for a walk every day and the staff helped them to achieve this if at all possible. The inspectors spoke with the cook during the site visit. They were well motivated, focused and enthusiastic about their job. They demonstrated a very good knowledge of the likes and dislikes of the current residents at this home, ensuring that they were offered alternatives to the main meals if it was not something to their liking. All the residents spoken to during the site visit commented on the improvement in the food and that the choice was better. The daily menu was on the blackboard in the dining room and residents were enabled to make their choice at the time of the meal. Two residents’ commented individually that they could have whatever food they asked for, however one commented that they were very happy with the food and had never thought to ask for anything different, but felt that if they asked they would be given their choice. One of the resident’s commented that the cook was aware of what they disliked and automatically offered a different choice if serving one of the foods they didn’t eat. Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 16 Fresh fruit, vegetables and meat were all sourced locally with regular deliveries. The cook utilised leftover vegetables to make homemade soups, which were served on a daily basis. One resident commented, “….at least the soups now taste of something real.” One of the relatives’ spoken to said the cook did a lovely birthday cake for their relative; they said that their relative loved their food and ate everything given to them. Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are confident in their right to complain and understand the process for doing so. EVIDENCE: The evidence in respect of service users and their relative’s access to the complaints procedure has not changed since the previous inspection. Service users are generally aware of the complaints procedure and were confident that this would be followed. Notices in respect of the complaints procedures were posted in prominent positions within the home. There had not been any recorded complaints received by the home. Relatives and residents spoken with during the visit were confident about how they raise any concerns with any member of the management team and did not feel that this would adversely affect their experience in the home. One resident stated that they had a very good relationship with the responsible individual who they felt was straight talking and took the time to talk to people. The Services policy in “Protection from Abuse” was suitable and staff were Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 18 booked for POVA training over the coming year. Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well maintained and comfortable environment. EVIDENCE: The home was generally in good decorative order, was clean, airy and tidy throughout and there were no unpleasant smells anywhere in the home at any time during the site visit. The home was generally well maintained and the inspector’s were told that bedrooms were redecorated before new residents occupied them. A couple of the unoccupied rooms at the time of the site visit needed new carpets; the inspectors were reassured that these would be replaced before they were next occupied. Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 20 There are a number of communal rooms that were all laid out comfortably and suitable for the groups of current residents. One larger lounge had been artificially divided in two, by having two television’s so that residents could sit around them and not be to far away, whilst this may make it easier to see and hear, this is only reasonable if both sets are tuned to the same channel, and further thought should be given to the function of this room and other lounges and whether adaptations such as a loop system should be considered to assist residents. Television’s throughout the home were only on whilst resident’s were watching them and were turned off during mealtimes, or when people werent in the lounge’s. A number of the residents spoken to stated that the proprietor had recently been arranging to update and change furniture in rooms throughout the home, so that the wardrobes and cabinets all matched. However one resident said that they had chosen not to have a change of furniture, as they were happy with what they had, even though none of it matched. The ground floor bathroom, which had been a problem at the last inspection, had been repaired. Work had also been done to divide this bathroom to make use of the spare space at the back of the room as a storeroom for archived notes. Following the last Environmental Health Officer visit, a number of changes had been made to the kitchen, including removing wall cupboards and doors on all cupboards to make for easier cleaning. Whilst touring the home it was noted that a number of the overhead lights had no lampshades attached and that there were still a number of neon strip lights; this did not encourage a feeling of homeliness. Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can be confident that the staff are only employed when the service is satisfied they have suitable background and skills to work in a care service. The staff training programme requires development to increase the teams’ skills in providing care to meet the needs of residents living at the home. EVIDENCE: The weekly rota identified that the service was maintaining 3 care staff on duty from 08:00 hrs to 20:00 hrs, with additional personnel for housekeeping and cooking duties. The total number of care hours provided totalled 420 hours per week and the management team reviewed the staffing levels regularly using a tool to calculate the number of staff required to meet residents assessed needs. Some of the staff were working double shifts as a regular feature of their working week. As this pattern may pose an increased risk of mistakes and or Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 22 abuse in delivering care, the management team should keep this under review. The files of three staff were examined during the inspection to assess the services compliance with a robust recruitment process. The evidence contained din files demonstrated that the documents required by The Care Homes Regulations 2001 were present in files and included CRB checks. The staff training programme has not been maintained in the past year, although there is a programme of mandatory training being undertaken by all staff and the management team monitor staffs attendance of this. The training programme should be further developed to ensure that the information from resident assessed needs and staffs’ supervision is included. Of the 14 staff employed in a care capacity in the service all but 3 have a minimum of NVQ level 2 or equivalent, with some staff holding higher qualifications. Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from day to day management of the service that is more stable with a greater sense of leadership. However, the appointment of a registered manager would benefit the service and ensure the management of the service is consistently delivered. EVIDENCE: The management post that had been vacant for the last year had not been filled at the inspection visit. The service was being operated on a day to day basis by a management team consisting of the responsible individual, the Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 24 Management consultant and a head of care. They have separated the duties of the manger with the RI taking responsibly for the premises and the business elements of the service with the Consultant supporting the head of care in the care delivery. The head of care had been appointed in October 2006, and was nearing the end of first three months probation at the time of the inspection visit. The consultant is working with the head of care to develop their skills and experience in management with the intention of proposing them as the registered manager. The home is currently trying to access the NVQ 4 in management of care for the head of care to attend. From discussions with the inspector it was felt that the head of care had good overall understanding of the care needs of the residents and appeared to be organised and focused in their work. The service has commenced a quality assurance process with questionnaires being distributed to residents and family members. The returns were being audited at the time of the inspection with a report of the findings being published. The consultant has been researching the guidance on the CSCI site in respect of the introduction of the Annual Quality Assurance Assessment and was preparing to issue the first statement in June 2007. The service does not manage any residents’ monies. The head of care had commenced the supervision of staff and the management team were developing their skills in this area. Documentation in relation to health and safety certification and processes were sampled and were all present and within their date at the time of this inspection. Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable ENVIRONMENT CHOICE OF HOME Standard No Score 1 2 3 4 5 6 Standard No 19 20 21 22 23 24 25 26 Score X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X N/A 3 2 3 Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 OP37 Regulation 17, Schedule 3, 14 Requirement An initial assessment must consistently provide detailed information about prospective residents needs and how these are supported. In order to promote a successful and appropriate admission process. Timescale for action 28/03/07 2. OP7 OP8 OP10 OP37 15, 17, Schedule 3 The care plans must be 28/03/07 monitored to ensure they contain all the information gathered at assessment about the individual and that this is consistently applied to provide the full benefits to residents and staff in providing care. The temperature at which medication is stored must meet the guidance provided by the Royal Pharmaceutical Society of Great Britain. This will ensure that medication does not deteriorate. 28/03/07 3. OP9 13 Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 27 4. OP12 OP14 13 The residents must be offered opportunity to participate in the daily routine and activity within the home in accordance with good practice guidance. and that these areas are recorded in care planning and daily records by staff. The registered person must ensure that the home has a staff training programme that meets the assessed needs of residents and the identified development required at individual staff supervision. 28/03/07 5. OP28 OP30 OP37 17 Schedule 4, 18 28/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The registered person should ensure that residents photos in residents’ medication records are dated to provide confirmation of their current identify to staff dispensing medication. The registered person should ensure that light fittings are suitable and that these are shaded. The registered person should ensure that there is a registered manager appointed to provide which supports staff and service users in the delivery good quality care. The registered person must ensure that staff receive formal line management supervision in accordance with the expectation of the national minimum standard of 6 times per year and that it is recorded. 2. 3. OP19 OP31 OP32 OP36 5. Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Marmora Residential Home DS0000060575.V328375.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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