Inspection on 30/05/06 for Marmora Residential Home

This inspection was carried out on 30th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 10/01/07

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 30th May 2006 10:30 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.V295674.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.V295674.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.V295674.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) 10th February 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. Addiotnal 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.V295674.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A wide range of evidence was considered to compile this report. In addition to the day spent at the home, the inspector reviewed written material submitted to the Commission since the last inspection . During the visit to the home, the inspector spoke to four service users, three relatives and a visiting community nurse. Time was also spent observing the care provided to people living at the home, reviewing records and in discussion with the Consultant employed by the organisation to address the requirements of the Care Standards Act 2000. Twenty-four national minimum standards (NMS) were inspected; of these 22 were standards considered key to the operation of a safe service, and of these key standards only 6 were met. It is of serious concern that not only are these a high number of key issues that are not complied with, but that the majority of the requirements arising from this inspection are repeated from previous inspections. Additionally the providors response to the previous inspection requirements in February 2006 stated that these standards had all been addressed. The CSCI has significant concerns about the quality of life experienced by people living at Marmora and is considering enforcement action to address the issues. What the service does well: What has improved since the last inspection? Service users terms and conditions are completed and held on their files. Records relating to the recruitment of staff have been provided on staff files. This supports a robust and safer recruitment process. Marmora Residential Home DS0000060575.V295674.R01.S.doc Version 5.2 Page 6 What they could do better: 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. Marmora Residential Home DS0000060575.V295674.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.V295674.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are terms and conditions agreements held on service users’ files. The assessments carried out prior to admission were not complete enough to demonstrate the service understood how they would meet the needs of prospective service users. EVIDENCE: The terms and conditions agreed between the service and the individual service user were present on service users’ files. The inspector viewed the assessments of four service users. At the previous inspection the forms used by the home had been changed to ensure they asked enough questions about the individual’s needs, abilities and preferences to enable the service to decide whether the service user could be supported by the home. However the gaps in these forms seen at this inspection means they Marmora Residential Home DS0000060575.V295674.R01.S.doc Version 5.2 Page 9 would not provide enough information to make such decisions or to help staff begin in completing a care plan with the service user. The home does not provide intermediate care. Marmora Residential Home DS0000060575.V295674.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Individual service users’ care plans were not fully completed or present in some cases. Service users did not appear to be involved in drawing up care plans, and staff’s daily recording did not support the arrangements laid out in individuals’ care plans. EVIDENCE: As part of the case tracking methodology used at the visit to the service, the care plans of four service users were requested by the inspector to understand how they informed staff to understand individual’s service users needs and aspirations. One service user’s file had no care plan in place. On the other three files, the care planning document was divided into five areas of “need” such as mobility, continence, food and drink and personal care. The amount of information to help staff to understand how they should support the service user varied. At worst they were not present at all. At best they were vague and did not provide staff with an understanding of how their support should compliment service users’ abilities to promote their independence. As an Marmora Residential Home DS0000060575.V295674.R01.S.doc Version 5.2 Page 11 example, in one service user’s plan the entry relating to personal care stated that “(the service user) does not have a social interest” and the instructions to staff state they should “encourage them to mingle with other residents”, in another it stated that the service user “can wash their face and hands” and that staff should “assist in washing and dressing”. The plans do not reflect the individual diversity of service users and ensure that staff practice respects this. None of the service users had signed their care plans and there was nothing in the documents that indicated that service users had been involved in drawing them up. The daily records relating to individual service users were mainly linked to their physical well-being. Health care entries were better in some areas of the service users’ files than others. The files generally contained information of health care visits to the service user and the outcomes, although these were not always transferred to the care planning portion of the document to inform staff. The inspector observed the lunchtime medication administration by a senior staff member. The staff member demonstrated a safe practice in dispensing and was able in discussions with the inspector to provide evidence of their understanding of appropriate practice and recording. Senior staff had received updated medication training. In the period since the last inspection a serious issue was reported to the Commission in respect of the misadministration of insulin injection to a service user. The primary responsibility for administration intravenous drugs remains with the Community Nurse, however the home is responsible for supporting the visiting nurse to the home and retains the medication on the premises. The issue was considered serious enough to require a Protection of Vulnerable Adults (POVA) referral and a strategy meeting was convened to consider the issue. As a direct result of this the responsible individual was required to review its procedure for supporting Community Nurses and ensuring that the processes protect service users, review the way in which staff understood their roles and responsibilities and how staff were supervised and inducted into the service, carry out development sessions with staff to ensuer they understand the philosphy of care and protecting service users rights to dignity and privacy. Additionally the Primary Care Trust Liaison Nurse provided staff with training in understanding the diabetes condition. Evidence of suitable levels of supervision and induction of staff was not found at this inspection, or was there any reference to the development sessions for staff. Service users were spoken with during the inspection and asked to consider how staff provide support that respects their rights to privacy and dignity. One service user stated, “Staff always knocked on the door” and “respect my right to remain in my room”. They also stated that staff addressed them politely and showed respect when providing personal care support. During the inspection a Marmora Residential Home DS0000060575.V295674.R01.S.doc Version 5.2 Page 12 visiting nurse was observed attending to a service user and carrying out treatment in the main lounge. During discussions with the nurse she stated that it was preferable to attend to people in their own rooms or occasionally the ground floor bathroom. She said that the current state of the ground floor bathroom did not make this appropriate and if staff did not take the service user to their room it was acceptable to the Community Nurse that the treatment was carried out in communal space, so long as this was not carried out in an eating area. The practice did not appear to respect service users’ dignity and privacy in receiving medical treatment in confidence, and staff’s actions in not insisting that service users were seen in private evidenced that they were not conscious of how this impacted on these rights. Marmora Residential Home DS0000060575.V295674.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is not sufficient consideration or provision of activities based on service users’ preferences and abilities. Staff do not include activities in their daily routine. Staff are polite and caring in their approach to service users. Service users acknowledged the shortfalls in the home, but liked living there. EVIDENCE: The inspector’s discussions with service users demonstrated that very little progress had been made in developing and providing activities. As at previous inspections there was not a consistently offered level of activities. No activities were provided for service users during the inspection, although service users reported that occasional games of dominoes or sing alongs took place depending on the staff on duty. There had been two outings in previous months to the theatre, which, for those service users who had been able to attend was greatly enjoyed. One service user said they had told someone they Marmora Residential Home DS0000060575.V295674.R01.S.doc Version 5.2 Page 14 enjoyed bingo, but did not know who they had spoken to. This service user did not have a care plan and therefore no record was held of their preferences. Staff spoken with during the visit were asked about the routine of the day, and their responses did not include any activities that were not associated with meeting physical needs. Visitors spoken with during the inspection also stated that the lack of activity provided in the home was a criticism. They identified that the staff were very busy with other tasks in the home, and that someone to co-ordinate a programme might be helpful to encourage regular sessions to take place. Service users and visitors spoken to on the day of the inspection reported that the home was welcoming and supportive in ensuring contact was maintained with visitors. Some representations made to the Commission prior to the inspection visit reported that the organisation of informing relatives of events had been poor with little notice provided to take part. Service users care plans also lacked detail in respect of contact with family and friends. The inspector observed staff interaction with service users during the day and particularly at the main midday meal. Staff were attentive and unhurried in offering service users’ support and choice in their mealtime. A service user who was distressed by the main meal on offer was immediately provided with an alternative of their choosing. Generally service users reflected positively on living at the home. They felt that things could be improved such as activities and staffing levels, but when asked made statements such as “I made a good decision to move in here” and “my health has improved since I have lived here, they look after me well”. Visiting families also stated that their relatives move to the home had been a positive choice and the home continued to live up to their expectations. They related this to the attitude and approachability of staff and the improvement in their relative’s health. Marmora Residential Home DS0000060575.V295674.R01.S.doc Version 5.2 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users and relatives are aware of a complaints procedure. The service did not demonstrate a robust response to POVA issues. 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. As previously stated in this report there had been an issue relating to the administration of insulin medication that had resulted in a POVA strategy meeting being convened. Whilst the home had taken appropriate action in response to ensuring the individual service user’s health was monitored, their action in determining the appropriate response to the individual staff responsibilities was less clear and required further consideration to ensure that the safety of service users was protected. This included supervision and induction processes to monitor the individual’s performance and competence in their role. Marmora Residential Home DS0000060575.V295674.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises are generally well presented, although the downstairs bathroom required urgent attention. EVIDENCE: Overall the building appears well maintained with suitable levels of equipment and furnishings to meet the assessed needs of service users. Some individual rooms would benefit from updated décor but were in good order. The downstairs bathroom had been affected by an accidental overflow to the bath that had resulted in the damaged floor covering being removed. At the time of the inspection, this had been the position for some time, but the room was still in regular use as the only ground floor facility. This does not provide a suitable environment for service users to receive personal support and was discussed with the responsible person at the time. It was stated that the whole Marmora Residential Home DS0000060575.V295674.R01.S.doc Version 5.2 Page 17 area including the bathroom was to be refitted to improve the layout. They were required to undertake this work as a matter of urgency to ensure appropriate and safe facilities were available to service users. Service users spoken with during the inspection particularly liked the way the home looked and appreciated both the spacious communal areas and the quality of their individual bedrooms. One service user’s relative survey returned after the inspection identified an issue with their relatives bedroom décor. The provider supplied additional details to the inspector in order to clarify this issue, including the consultation carried out with the service user. This evidence will be considered further at the next key inspection of the service. Marmora Residential Home DS0000060575.V295674.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staffing numbers and skills were sufficient to support the basic needs of service users, but did not sufficiently support staff to meet service users’ holistic needs. The gaps in staff training do not demonstrate an adequate level of competency to meet service users’ needs. EVIDENCE: According to the staff rota the staffing numbers are maintained at four care staff 08.00hrs to 20.00hrs, including senior staff in charge of the shift and additional housekeeping and catering staff. The consultant supporting the service provided details of the staffing numbers, however the Commission has not been supplied with evidence that this number has been arrived at following a calculation of staff requirements identified from service users’ assessed needs. Although the home has not been operating at full capacity for some time, from the inspector’s observation and discussions with staff and service users, the daily routines carried out by staff did not provide sufficient time for staff to spend time with service users in tasks outside of meeting basic care needs. Service users stated that they felt staff were hurried and unable to spend time with them, and one example given was that there was not enough staff available in the evening to allow service users to go to bed when they Marmora Residential Home DS0000060575.V295674.R01.S.doc Version 5.2 Page 19 wished. They stated that they staff started “putting people to bed straight after tea, because they had to get so many in before the night staff come on”. Because care plans or daily records were not sufficiently instructive as to the choices and routines adopted by the staff, it is not possible to determine if and why such practice is carried out. Those files sampled by the inspector contained the required documentation to demonstrate a robust recruitment procedure had been adopted. This included CRB and POVA first checks. This is an improvement since the last inspection. Staff spoken with were conscious of the recruitment processes and the level of evidence they had been asked to supply to the home to determine their appointment. The staff training programme had commenced with Moving and Handling training for all staff. A senior staff member had been given the task of coordinating the staff training needs and drawing up a programme to meet these. From discussions with staff members it was apparent that there was difficulty in gaining all staff’s commitment to involvement in training and recognition of the authority that the staff member responsible held. Therefore the planning of further training in mandatory and skill development topics was not progressing. A training session arranged by the PCT liaison nurse in diabetes care had been arranged as a specific outcome of the POVA strategy meeting. The nurse reported that during this session the responsible individual interrupted and removed staff to attend to service users, although she understood that the staff were not on rota. Following a meeting with the CSCI the proprietor stated that this was a misconception on behalf of the nurse and that the staff member was an additional attendee to the training session, as they were on duty that day. Generally the emphasis placed on training and staff development required serious consideration by the provider to ensure that there is a shared ethos in the home of learning and development as a priority. Marmora Residential Home DS0000060575.V295674.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service does not benefit from consistent leadership to support the service’s development. Staff do not feel supported by the management arrangements in the home. The home does not consult service users or their supporters’ views about the quality of the service and how they should improve. EVIDENCE: The registered manager’s post has been vacant for some months and the consultant employed by the company reported to the inspector that recruitment efforts had been unsuccessful to date. The inspector discussed the Marmora Residential Home DS0000060575.V295674.R01.S.doc Version 5.2 Page 21 need to develop a strategy for the interim and long term management of the service with the responsible individual at the inspection and a meeting was arranged following the inspection to discuss this further. From the discussions with service users and staff on the inspection visit, it was clear that there was a lack of confidence in the current management arrangements for the home, due to the responsible individual’s lack of experience in care settings and the availability of the consultant on a day-today basis. For example senior care staff reported that they weren’t adequately supported by the interim management arrangements when tasks had been delegated to them. They reported that they did not feel that they carried sufficient authority to gain staff engagement and therefore there was little progress in achieving their goal. Staff supervision had not commenced at the point of the inspection, although staff minutes contained reference to a discussion about the start date for regular staff supervision by the consultant. The lack of supervision arrangements does not support the development of staff conduct and competencies and will affect the delivery of a quality service. The service does not manage service users’ monies. There isn’t a quality assurance system operating in the home. This does not provide an opportunity for service users and relatives to contribute to the services quality development. Documentation in relation to health and safety certification and processes were sampled during the previous inspection visit and were still within their date at the time of this inspection. Marmora Residential Home DS0000060575.V295674.R01.S.doc Version 5.2 Page 22 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 CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 X N/A 1 X 3 Marmora Residential Home DS0000060575.V295674.R01.S.doc Version 5.2 Page 23 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 OP4 Regulation 14 Requirement The registered person must ensure that all service users have a needs assessment prior to admission. This is a repeat requirement. The registered person must ensure that there is a care plan for each service user that provides instruction to staff in how to meet the individual’s assessed needs. This is a repeat requirement. The registered person must ensure that service users’ opportunities to exercise choice in their daily lives and activities is maximised and that these areas are recorded in care planning. This is a repeat requirement. The registered person must ensure that they adhere to the home’s policy and practice in respect of protection of vulnerable adults. This is a repeat requirement. DS0000060575.V295674.R01.S.doc Timescale for action 31/08/06 2. OP7 OP8 OP4 OP10 15 30/09/06 3. OP12 OP13 OP14 13 30/09/06 4. OP18 13 31/08/06 Marmora Residential Home Version 5.2 Page 24 5. OP19 13 6. OP27 18 The registered person must ensure that the appropriatley maintained at all times and protects service users from harm. Specifically this referes to the ground floor bathroom. The registered person must ensure that the staffing levels and arrangements are responsive to the assessed needs and choices of service users. This is a repeat requirement. The registered person must ensure that the home has a staff training programme that meets national training workforce targets. This is a repeat requirement. The registered person must ensure that there is a strong management ethos being adopted in the home, which supports staff and service users in the delivery good quality care. This is a repeat requirement. The registered person must maintain a system that reviews the quality of care at regular intervals, and provides an action plan in response to the findings of the consultation. This is a repeat requirement. 31/08/06 31/08/06 7. OP28 OP30 OP38 OP4 18 31/08/06 8. OP31 OP32 8,9,12 31/08/06 9. OP33 24 30/09/06 10. OP36 18(2) 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. This is a repeat requirement. 31/08/06 Marmora Residential Home DS0000060575.V295674.R01.S.doc Version 5.2 Page 25 11. OP37 17 The registered person must ensure that records required by regulation are maintained. This is a repeat requirement. 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Marmora Residential Home DS0000060575.V295674.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 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.V295674.R01.S.doc Version 5.2 Page 27 - 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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