Inspection on 02/04/08 for Rose Martha Care Centre

This inspection was carried out on 2nd April 2008.

CSCI found this care home to be providing an Adequate service.

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

Rose Martha Care Centre 03/04/09

Rose Martha Care Centre 18/10/07

Rose Martha Care Centre 23/04/07

Rose Martha Care Centre 27/04/06

Rose Martha Care Centre 18/10/05

Rose Martha Care Centre 24/05/05

Rose Martha Care Centre 05/02/05

Rose Martha Care Centre 05/07/04

Rose Martha Care Centre 10/02/04

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 Rose Martha Care Centre 64 Leigh Road Leigh On Sea Essex SS9 1LF Lead Inspector Sarah Hannington Unannounced Inspection 09:15 2nd April 2008 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 Rose Martha Care Centre DS0000015465.V361701.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. Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rose Martha Care Centre Address 64 Leigh Road Leigh On Sea Essex SS9 1LF 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) 01702 482252 01702 716887 rose.martha@ashbourne.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited vacant post Care Home 76 Category(ies) of Dementia - over 65 years of age (76), Old age, registration, with number not falling within any other category (76) of places Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Number of service users for whom personal care is to be provided shall not exceed 76. (Total number not to exceed seventy-six). Personal care to be provided to no more than seventy-six service users over the age of 65 years. (Total number not to exceed 76). Personal care to be provided to no more than seventy six service users with dementia over the age of 65 years. (Total number not to exceed 76). 18th October 2007 Date of last inspection Brief Description of the Service: Rose Martha Care Centre is a purpose built establishment situated in Leigh on Sea. The home is close to local amenities and access to local bus and train routes is good. The home provides residential care for up to seventy-six older people. The registration category also permits the home to provide care for older people who have dementia. The home also offers `step down`, a scheme whereby arrangements exist with the local hospital where beds are contracted for those patients who are assessed as suitable for residential care. All bedrooms have en-suite facilities for residents. The communal areas consist of two lounge and dining areas on both the ground and first floors. The home also provides a designated smoking area, visitors/hairdressing room and an activities room. Access to the first floor is via a passenger lift. The gardens are well maintained. The home offers parking to the front of the property. Inspection reports are readily available for visitors to the care home and are displayed in the main reception area. Upon request, prospective residents and/or their representatives can have a copy of the last report. A copy of the homes Statement of Purpose and Service Users Guide is also readily available and accessible. The range of fees is £379.00 to £421.00 for a social services bed and £525.00 to £700.00 for a private bed. Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 Star. This means the people who use this service experience adequate quality outcomes. The inspection took place over ten hours and was carried out as part of the annual inspection programme for this home. This inspection was conducted with assistance from the newly appointed manager. Additionally the home’s Operations Manager was also present throughout the majority of the inspection. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. The site visit also focused on any requirements and recommendations from the last key inspection. Prior to this site visit CSCI (Commission for Social Care Inspection) sent out surveys to all interested parties, however at the time of writing this report none have been returned. A number of relatives, residents and staff were spoken with during the site inspection and a tour of the building was undertaken. Additionally the manager was sent an (AQAA) Annual Quality Assurance Assessment form by us (CSCI) that asked how well the home is meeting the needs of the people who live at Rose Martha Care Centre. What the service does well: What has improved since the last inspection? Staffing levels have improved. Training showed that nearly all the staff team have now completed safeguarding and general training. Dementia training has been carried out and a dementia specialist has been employed by the organisation. Induction for staff has improved. The manager has updated the Statement of Purpose and Service Users Guide. Service at mealtimes has also been improved. Vanity sink units have been ordered. Odours throughout the home have eliminated. A new patio area has been laid. Care plans and risk Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 6 assessments have been improved. General recording in personal care files has started to improve. 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. The summary of this inspection report can be made available in other formats on request. Rose Martha Care Centre DS0000015465.V361701.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 Rose Martha Care Centre DS0000015465.V361701.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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A robust assessment process reassures prospective residents that their needs could be met before they move to the home. EVIDENCE: The Manager states on the AQAA that, ‘Statement of Purpose and Service User guides are available. All prospective clients have a detailed pre-assessment to ensure the home is able to cater for their care needs. Prospective clients are able to spend time in the home prior to making a decision.’ The home provides a good statement of purpose that is reviewed on a regular basis. Documentation around the areas of pre-assessments, risk assessments, care plans and consultation with individuals were inspected. Assessments included details such as diets, weights and nutrition, mental and physical well being. Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 9 Personal safety and risks, residents and families views, wishes and likes and dislikes were also considered. Documentation viewed showed that it gave sufficient detail about individual needs. The majority of relatives and residents stated that they had a number of visits, prior to any placement being offered. They also confirmed that consultation regarding pre-admission assessments and the care plan went ahead and that they had been given sufficient information to make an informed choice. No intermediate care is provided. Rose Martha Care Centre DS0000015465.V361701.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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Rose Martha staff are successful in delivering appropriate care, although this may not always be documented appropriately. EVIDENCE: The Manager states on the AQAA that, ‘Care plans have improved to reflect the needs of the service users.’ In five out of the eight care plans inspected, there was evidence to show that a good standard of recording is in place. In all care plans information such as weight monitoring, fluid in takes, and falls, dementia and communication needs were included. However recording of individuals’ needs is not consistently met for all, for example, the linking up of the recording of the daily notes, professional visits (such as GP’s, hospital visits) and general recording of the changing needs in care plans and risk assessments. The care plan is not used as a working document and does not consistently reflect for all residents the current care being delivered. Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 11 Speaking with many of the staff team it is apparent that they are starting to listen to residents’ views and include these in some of the daily notes looked at, this is an improvement. Additionally verbal updates amongst the team, such as, handovers, meetings and supervisions are now regular and part of the routines of the home. The manager states on the AQAA that, ‘We plan to provide ongoing training for the continued improvement of care plans and care profiles.’ Discussions with staff team evidenced that management have been proactive in raising awareness with them about person centred strategies. However this is at its early stages, as it is being developed at a realistic pace for some of the complex issues that the team face and which some residents’ may present. The majority of residents spoken with stated that they felt all staff had been more attentive lately and felt staff were better informed about their own individual care needs. Relatives spoken with stated that staff informed them on a regular basis of any issues or concerns they may have about their relative. They also felt that staff are supportive and easy to speak with. The manager has made it clear that she recognises that there is a need for progress to be made at including residents more, for example, having residents on interview panels when employing new staff and getting them involved in some of the general decisions about the home. Additionally rethinking some of the systems of checking staff practice by using more observational systems than at present. The manager will also be re-organising how the care information is provided to staff, for example she may keep the main essential information in a main file, but produce a ‘snapshot’ version of the care plan to highlight better how individuals like their care to be delivered. This will be a person centred document that will include their views, wishes and aspirations. This would also enable any agency, new staff or staff in general to have a quick useful reference tool to aid them in their busy day. Additionally this will provide an opportunity for all residents’ views to be fully and realistically included and acted upon. The Manager states on the AQAA that, ‘All service users have access to outside professionals to include doctors, district nurses, opticians, chiropodist and complimentary therapists.’ It was evident throughout care records and discussions with residents that they all have regular access to a number of health services including a choice of GP, dentist, chiropodist and any other specialist service that maybe required. All of the residents spoken with stated this to be the case and daily notes related to these visits. Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 12 Additionally during the site visit two GP’s who were carrying out routine visits, stated that they had no concerns about the care given to residents and felt it was to a good standard. One GP specifically stated to us that, ‘ I think that the staff at Rose Martha are very vigilant in calling out GP’s for the care of the residents and this is a positive and a caring approach. Both GP’s informed us that they felt the staff had good skills that enabled them to follow any guidance given by themselves or their team, and that overall Rose Martha staff worked well and in partnership with the district and community nurses provided. Speaking with many of the residents the majority felt happy and supported by staff and felt that they were caring, supportive, protected their dignity and respected their rights. Residents stated that, ‘ I have a good choice of having a bath or shower.’ ‘Staff respect my choice to be left alone whilst in the bath but I know they are outside waiting and listening if I need them.’ ‘ I only have to ask the staff for something and its done.’ Medication training has taken place for all staff who administer medication. Stringent audit checks on systems are used and regular in house monitoring of all staff that administers medication by means of observation and in house supervisions are now being implemented. A Monitored medication dosage system is in place for each resident. Medication is stored in lockable cabinets and trolleys. The administration records were being maintained in accordance with agreed procedures. Record sheets had been signed for with no omissions or gaps. Discussion with staff evidenced they knew procedures well and were aware of individual need. Residents who self-administered some minor medication were supported in a safe and appropriate manner. Rose Martha Care Centre DS0000015465.V361701.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most residents can be sure that they will be offered appropriate activities, although this may not always be the case for those with more complex issues or who chose to stay in their private rooms for a number of reasons. EVIDENCE: Overall the majority of residents felt that they had choice and autonomy. Residents spoken with stated that they had the choice regarding when to get up and go to bed, had a choice of foods readily available and were able to carry out their daily routines as they wished. Throughout the day residents were seen to have their own newspapers, crosswords, books and interests of their choice. In three out of the four units, staff were observed to have meaningful interaction with individuals. Staff were chatting, relaxed, and had an easy rapport with residents’. Throughout the day, care staff were seen to be initiating activities that stimulated and supported individuals emotional and physical needs. In one unit, again throughout the day, care staff had very little interaction with the group or with any one individual, although when Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 14 supporting residents to eat meals there were some minimal attempts to engage individuals in conversation. Residents stated that, ‘ Staff always give me a choice of what I do inside of the home.’ ‘ I often go out for meals with the activity coordinator and have got to know staff at the local Indian restaurant across the road.’ The Manager states on the AQAA that, ‘Weekly activities programme displayed throughout the home. Encourage clients to maintain links with the local community through trips out to shops, restaurants and clubs. Visits by local complimentary therapists, PAT dog and outside entertainers.’ There is funding for two activity coordinators but at present there is only one in post. However this vacant post has already been filled and a starting date has been agreed upon. Speaking with the activities coordinator it was noted that some good work was being carried out with individuals and observation of one of the group sessions getting residents to recall past events, such as, work, family and significant life events, showed that it was interesting, fun and uplifting for the individuals to carry out. The activities coordinator herself is very knowledgeable, enthusiastic and demonstrated a good understanding and philosophy of care towards the residents. The manager states on the AQAA that there is ‘Ongoing training for all staff in dementia care awareness.’ The activities coordinator is due to start training around dementia care, this will enable her to further develop activities and stimulation for that specific resident group. Additionally the organisation has recently employed a Dementia specialist who will be developing strategies and training alongside the management and staff team of Rose Martha. This is a positive step forward and a good outcome for the residents. At present there is a regular four-week activities programme up and running. One activity is the gardening project, a hobby once enjoyed and shared by many of the residents that were spoken with. This activity is carried out in the new patio area and directly leads from the conservatory room. This conservatory room may also be used as the main activities room. If this space is used, as the manager wishes it to be, then it has a number of advantages for the residents. One being it provides a direct route to the garden/patio, where this much-enjoyed activity of gardening will take place and secondly for those not is able to physically join in they will be able to observe. Additionally this area may give those with complex needs some type of stimulation by observation, as well as a chance to use the garden area indirectly. The activities area presently used may be re-organised into a sensory type room. This kind of activity would be very beneficial for many of the residents and be Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 15 well situated, particularly as it is based near the high dependency unit. Additionally it would have the double benefit of encouraging staff to be more interactive, creative in their approach of supporting the many complex needs that they face on a day-to-day basis. It is appreciated that these plans may take some time to develop fully, however it is noted that during feedback with both of the managers that a lot of enthusiasm, time, dedication around developing these areas and improving the lives for all residents at Rose Martha is a real drive and an exciting time for not only the team and home, but also for the organisation. The Manager states on the AQAA that, ‘Four weekly menus now available in large print to enable clients to chose at point of service where possible.’ Food, drinks and meals eaten and given to individuals are better recorded and easier to monitor. Residents are encouraged to have a choice of foods. The majority of residents informed us that the menus reflected their tastes. Food served on the day smelt and looked appealing and was presented nicely. Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 16 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are systems in place to ensure that peoples views are listened to, acted upon and support residents to be protected from abuse. EVIDENCE: There have been no complaints received by the manager or made to CSCI or any other agency since the last inspection. The manager has a good complaints procedure in place. All complaints are recorded, maintained and outcomes recorded. All residents spoken with are aware of their rights and have a good idea of what may constitute abuse. They all had a clear idea of what they would do if they wanted to make a complaint. All commented that they would feel confident that the manager would follow these up to their satisfaction if need be. All staff have attended safe guarding (protection of vulnerable adults) training. Speaking with staff they a good awareness around these issues. Safe guarding training forms part of the induction process for all new staff. Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 17 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a clean safe environment. EVIDENCE: A tour of the building took place and overall Rose Martha provides a clean and homely place for all the residents. Rose Martha provides plenty of good space, light and private rooms for residents and their families to use. There were no apparent odours in communal or private rooms and the place was clean, tidy and smart. Resident private rooms were personalised and many of the maintenance issues raised at the last key inspection had been resolved. Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 18 At the last key inspection some of the sink surrounds were highlighted as a serious concern. These have now been ordered and urgent areas identified will be addressed as soon as they arrive. Outside on the ground floor and leading from the conservatory, a new patio area has been laid and garden furniture is soon to be provided. Since the last inspection all toilets, baths and showers are all in working order. Water temperatures are corrected and hot water supplies have been improved. A new maintenance person has been employed and general jobs needed around the home are gradually being achieved on a regular basis. Residents spoken with informed us that they are getting regular access to showers and baths. They also felt that since the maintenance person has been in post, maintenance issues that they raise are dealt with quickly and efficiently. Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. Residents are protected by staff recruitment, induction and training. EVIDENCE: The manager has been successful in achieving a full staff team at Rose Martha. The last two posts are waiting for staff to be cleared on safety checks and new start dates have been set. (One of these new staff being the other activities coordinators post.) This is a good achievement since the last inspection. Since this recruitment drive, the home is fully staffed on all shifts. Agency use has ceased apart from the occasional unforeseeable gaps. Staff spoken with stated that they really appreciated the difference that having regular staff had made to their daily working lives. They felt it gave them greater confidence in being able to share information; to know that things handed over would be picked up on, carried out and completed. Some staff expressed that it was becoming a less stressful environment as a result. Overall by establishing a full staff team it has improved the quality of care given to the residents’ and has improved the outcomes for them. Many residents had commented that they were very pleased the manager had employed new staff, as it was nice to have familiar faces on the different shifts. Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 20 Staff files were reviewed and recruitment records evidenced that application forms were completed, interviews were held, two references obtained, criminal records bureau checks undertaken and proof of ID and photograph kept. Contracts of conditions of service and job descriptions were issued to new staff. Training opportunities for all staff are good and include manual handling, health and safety, first aid, dementia awareness, fire awareness, safeguarding and infection control. Staff spoken with reflected that courses undertaken had developed a better understanding of the residents that they worked with. New staff spoken with evidenced that the induction process is to a good standard and were able to give a good account of what they had learnt and knowledge gained from this. Additionally new staff are now shadowing the more experienced staff for a period of weeks, this practice allowed them to build a rapport with individuals and get to know needs well, before working independently. The majority of residents stated that they are well looked after by staff and felt that the staff knew their needs well. No concerns from residents, relatives or staff were raised regarding staff support. All staff spoken with confirmed that regular supervision; staff meetings and support in general had improved and is regular. Overall training and meetings are much more person centred focussed on delivering good care and improving the outcomes for all residents. Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. The management of the home is stable which ensures the health, safety and welfare of all residents. EVIDENCE: The Manager states on the AQAA that, ‘the manager is an RGN with over 30 years experience in health care. She is currently undertaking the Registered Managers Award.’ The home has a competent and skilled new manager who has been in post over the six months. The new manager has developed and put into place systems to ensure that the health and safety of the people living in the home and staff is promoted. Management systems in place are improving and there is a shift towards ensuring that the home is run in the best interests of the Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 22 residents. The manager has provided a strong support system by means of working closely with her deputy manager and area manager. However she is presently identifying new ways to expand these support systems by delegating other resposibilities to ‘key’ staff. This will not only raise staff awareness, good practice and bond the team, it will let all staff have the chance to be part of the development process of Rose Martha . The AQAA that was sent by us was completed to an adequate standard. The manager needs to develop the next AQAA by covering all of the outcome areas required, making sure that a wide range of evidence supports the written information provided. For example in one section it may be asking about standards 7, 8, 9 and 10 and in response by the manager only standard 7 has been partly addressed. Again some of the AQAA asked the manager about improvements made, however this was not always completed or fully addressed in parts and needed to be expanded upon, rather than using a one or two line response. Additionally information which was requested to support us prior to any site inspection being carried out, such as, the latest regulation 26 visit, the Annual Quality Assurance outcomes, the residents, staff, relatives, other professionals’ or visitors, surveys to be returned by a deadline was not achieved. The Manager states on the AQAA that, ‘the home undertakes quality audits on a monthly basis. The Manager has an open door policy for service users, their families and other interested parties to discuss any issues arising.’ Although there is a good annual quality assurance package in place which the organisation carry out, the manager is in the process of developing a more person centred approach. This will include views from all residents, relatives and other professionals and persons that may come in contact with the home on a regular basis. This will finally be made into a report with the outcomes, achievements and actions that will be taken as a result of the Quality monitoring Survey carried out. This documentation needs to be made available to all interested parties and displayed within the home and a copy sent to us. These results could also prove useful to the manager when completing any AQAA that may be sent. Policy, procedures, documentation and new finance systems put into place by the organisation evidence that resident finances are protected. All health and safety checks that were inspected are up to date. Within the fire records looked at and staff practice around fire evacuation drills were found to be to a good standard. A good proportion of relatives spoken with expressed that they felt the manager had improved the quality of life in general for their relatives, by good her good leadership of the team and by recruiting more permanent staff. Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 23 Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 24 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 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 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15(1) Requirement Care plans must reflect all resident’s current health needs and how they are to be met. Care plans must provide evidence that the home understands what support each person needs, and ensure that staff have clear guidance on how to meet each person’s individual need. This is a repeat requirement previous timescale of 18/10/07 not fully met. Risk assessments must be reviewed and clearly detail the preventative care that staff are expected to provide. This is a repeat requirement previous timescale of 18/10/07 not fully met. All residents need to receive/have the opportunity to participate within a meaningful activity programme. This refers specifically to those people who are confirmed to their rooms or have complex needs, including dementia. This is a repeat requirement previous timescale of DS0000015465.V361701.R01.S.doc Timescale for action 01/09/08 2. OP8 14 (2)(a)(b) 01/09/08 3 OP12 16(2)(m) and (n) 01/12/08 Rose Martha Care Centre Version 5.2 Page 26 18/10/07 not fully met. 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 OP33 Good Practice Recommendations Quality-monitoring information of residents, relative and other professionals views need to be collated. The action plan with outcomes to be kept on the premises and made available for inspection and to all other interested parties. Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Rose Martha Care Centre DS0000015465.V361701.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!