Inspection on 23/04/07 for Rose Martha Care Centre

This inspection was carried out on 23rd April 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

Rose Martha Care Centre 03/04/09

Rose Martha Care Centre 02/04/08

Rose Martha Care Centre 18/10/07

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 Michelle Love Unannounced Inspection 23rd April 2007 08:00 23/04/07 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.V336277.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.V336277.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-homes.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Mrs Karen Johnson 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.V336277.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). 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. The range of fees as detailed at the last key inspection (dated 26.4.2006) are £352.73 for those residents placed by Social Services, £383.81-£410.48 for those residents who have a diagnosis of dementia and £525.00-£650.00 for those residents privately placed. Additional charges to residents include chiropody, hairdressing, newspapers, personal toiletries and massage therapy. Rose Martha Care Centre DS0000015465.V336277.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced `key` site visit whereby the majority of all key standards were inspected. The visit was carried out by two inspectors, Michelle Love and Carolyn Delaney. The site visit commenced at 08.30 a.m. and finished at approximately 19.00 p.m. As part of the inspection process a range of records relating to individual residents and members of care staff were examined i.e. care plans, risk assessments, healthcare records, menus, nutritional records, staff files, staff rosters etc. In addition several residents and staff were spoken with at the time of the site visit and ten surveys were randomly forwarded to resident’s relatives and/or representatives seeking their views as to the care and support provided at Rose Martha Care Centre. It was disappointing to note that only four surveys were returned to the Commission and these comments have been incorporated into the main body of the report. On the day of the site visit the acting manager was on annual leave. The inspection was conducted with the assistance of the deputy manager and other senior members of staff. The Commission recognises that the newly appointed acting manager has only been in post since the beginning of April 2007 and that the majority of the findings highlighted within this report are not reflective of their poor management. As a result of the acting manager not being present at the site visit a meeting to discuss the findings was conducted between the Commission, the acting manager and the registered providers operations manager one week later. What the service does well: What has improved since the last inspection? Rose Martha Care Centre DS0000015465.V336277.R01.S.doc Version 5.2 Page 6 What they could do better: It was disappointing to note that many shortfalls were identified at this inspection. It was of concern that not all prospective residents had been assessed prior to admission and a care plan/risk assessments devised detailing individual resident’s care needs and how these were to be met by care staff had not been recorded. Although this was not highlighted at the last inspection to the home, this has been identified previously on several occasions. The homes Statement of Purpose and Service Users Guide needs to be reviewed and updated so as to contain accurate information advising people of the services and facilities provided at Rose Martha Care Centre. Although there is an activity programme there is little evidence to suggest that residents are enabled to participate within a programme of activities and/or meaningful occupation. The range of activities currently on offer, are unimaginative and do not offer, varied opportunities for individuals to maintain skills and independence. This refers specifically to those residents with dementia and/or complex needs. Throughout the site visit there was little or no evidence to indicate that residents are empowered or enabled to make decisions and/or choices about their care and daily living within the home. Many routines within the home are task orientated. There is evidence to suggest that staffing levels within the home are not always maintained and this is to the detriment of current residents. Deployment of staff within the home is intermittently poor and for long periods of time residents are left unsupported by some members of care staff. Staff recruitment procedures are not in line with regulatory requirements and do not protect residents from possible harm or abuse. Some deficits were observed in relation to staff training, staff induction for new staff and formal supervision. The Commission is concerned that despite previous assurances by the registered provider to address identified shortfalls, progress and improvement at the last inspection appears to have been short lived. It is evident that the absence of the registered manager and their subsequent resignation in recent months has had a detrimental affect on the day-to-day running of the home. The Commission is concerned that whilst there was no significant management cover at the home, steps were not undertaken by the registered provider to ensure that the senior management team at Rose Martha Care Centre were adequately supported or given appropriate training and induction to their new roles. Rose Martha Care Centre DS0000015465.V336277.R01.S.doc Version 5.2 Page 7 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.V336277.R01.S.doc Version 5.2 Page 8 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.V336277.R01.S.doc Version 5.2 Page 9 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): 1, 3 and 6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a Statement of Purpose and Service Users Guide depicting information about the home and providing prospective residents and their representatives with information they need to make an informed choice as to whether or not Rose Martha Care Centre is the right home. The home has a formal system for assessing the needs of prospective residents prior to admission, however this was not undertaken for all newly admitted residents and there was little or no evidence to indicate that prospective residents and/or their representatives had been given the opportunity to visit the home prior to admission. EVIDENCE: Since the last inspection both the Statement of Purpose and Service Users Guide have been reviewed and updated. The deputy manager advised inspectors that neither document has been circulated, as there are still some minor amendments to be made. One relative confirmed that when their member of family was admitted to the care home they were provided with a Rose Martha Care Centre DS0000015465.V336277.R01.S.doc Version 5.2 Page 10 “glossy leaflet” which was designed at `marketing the home` rather than providing information about the home and the services provided. The Service Users Guide for individual residents did not include information relating to fees payable for services provided, arrangements for paying and additional costs incurred or whether or not there are different charges for people who have all or part of their care funded by a local authority or primary care trust. On inspection of seven short-term respite care files, no pre admission assessment had been completed for two residents. No information was recorded pertaining to the resident’s needs or consideration of the specialist care the resident may require. This is of concern as some people may receive very poor quality of care. Following discussions with the deputy manager and other senior members of staff it appears that the acting manager made the decision to admit several residents over the Easter weekend, despite misgivings being voiced. Following the site visit inspectors met with the acting manager to discuss the inspection findings. In relation to the above the acting manager advised that all prospective residents had been visited, either in the local hospital or in their own home, however there had been some system failures. Little or no evidence was available to indicate that prospective residents and/or their representatives had contributed to the assessment process or been offered an opportunity to visit Rose Martha Care Centre prior to admission. The homes Statement of Purpose states “Rose Martha Court will formally write to the service user to confirm that we can meet their needs”, however no evidence was available to indicate that this happens in practice. Rose Martha Care Centre DS0000015465.V336277.R01.S.doc Version 5.2 Page 11 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 poor. This judgement has been made using available evidence including a visit to this service. The home has a comprehensive system and format for recording individual resident’s health, personal and social care needs, however not all residents were noted to have a detailed and comprehensive plan of care, some were seen to be poorly developed and did not fully reflect the person’s needs. Medication systems within the home were generally seen to be appropriate, however some issues relating to poor recording and administration of medication to residents were highlighted. EVIDENCE: On inspection of eleven individual care plans for both short-term care residents and permanent residents, information recorded was inconsistent and did not depict in sufficient detail information pertaining to resident’s health, personal and social care needs i.e. some residents were noted to only have 2-3 elements recorded whilst others had 7-8 elements recorded. The care plan for one resident only made reference to their personal hygiene needs and their dietary requirements. No other elements were recorded i.e. communication, social/leisure, medication, mobility, mental health/well being etc. Rose Martha Care Centre DS0000015465.V336277.R01.S.doc Version 5.2 Page 12 None of the care plans inspected recorded individual resident’s preferences or documented where individuals are independent/require specific support i.e. the care plan for one resident stated that in relation to their personal hygiene they should be encouraged to be as independent as possible and may need some assistance. The care plan failed to depict what elements the resident can do independently and what areas they require assistance. It was positive to note that formal assessments relating to dependency, manual handling, pressure area risk assessment, nutrition, and continence had been completed within all care files examined. The assessment pertaining to manual handling does not include the type of hoist or sling to be utilised. Risk assessments were recorded, however not for all areas of assessed risk i.e. one care plan made reference to the resident being at high risk of pressure sores, requiring the assistance of 1x carer to help with day to day living activities, to be offered plenty of fluids, falls and vascular dementia. The only risk assessments documented related to falls and nutrition and not pressure area care, dementia and how this affects the resident on a day-to-day basis. Another resident’s care plan made reference to them having no verbal communication and using picture cards. This was not highlighted as a risk area, however during the site visit, inspectors observed that the resident throughout the day did not have access to their communication cards and on two occasions were very distressed and care staff were slow to respond to the resident’s needs and it was not until inspectors intervened that support was provided. This was not an isolated incident. Daily care records were not written after every shift and for those residents admitted on short term care, it was observed that some had not been commenced on admittance to the care home i.e. one resident was admitted on 6.4.07, however daily care records were not written until 9.4.07. Additionally no records were recorded on 14.4.07 and 15.4.07. Daily care records are a good source of evidence to show that care is being provided, as detailed in the care plan. Daily records when well written, help ensure a consistent approach and good quality of care for service users. Care plans did not consistently evidence residents and/or their relatives wishes pertaining to end of life/terminal care issues. There was little or no evidence to indicate that the care plan had been devised with the resident and/or their representative or involved in the care planning process. This is contradictory to what is recorded within the Statement of Purpose. This states “Service users (or their representative with permission of the service user) are encouraged to become involved in the care planning process and will be fully consulted at each stage of the care plan”. A Medication Audit was conducted by the deputy manager on 18.4.07 and the overall percentage of compliance recorded 93 . Rose Martha Care Centre DS0000015465.V336277.R01.S.doc Version 5.2 Page 13 The homes medication storage facilities were seen to be appropriate and secure. A medication profile was completed for all residents detailing allergies and details of resident’s medical conditions. On inspection of Medication Administration Records (MAR) some omissions of signatures were observed whereby staff had not signed the records to indicate that medication had been administered to and received by individual residents. On inspection of MAR records for one resident, it was not possible to determine that medications had been given to the resident and/or to assess when medications were received/commenced. The deputy manager was advised that this resident’s medications were extremely important as they control Parkinsons Disease and must be given regularly. Records for when medications are returned to the pharmacy were observed to be appropriate and detailed. Records indicate that a senior member of staff administered the wrong medication to one resident recently. Poor recording was noted in respect of the actual medicines given, possible side effects and what monitoring occurred, however good recording was noted pertaining to the action taken. The training matrix submitted to inspectors indicated that 13 members of staff have up to date medication training. Rose Martha Care Centre DS0000015465.V336277.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 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. An activity programme is available for residents, however resident’s needs pertaining to their personal preferences for leisure and social activities are poorly documented and there is little evidence to depict specific activities undertaken by individual residents. Meals provided to residents are adequate. EVIDENCE: The home employs an activities co-ordinator for 30 hours and another person for 7 hours per week, Monday to Friday. The deputy manager advised inspectors that the registered provider is currently advertising for an additional activities co-ordinator for 30 hours per week. On the day of the site visit, activities for that week were displayed in the main reception area and these included hairdressing, knitting, quiz, stroll, bingo, flower arranging and a visit from the local church. On inspection of eleven care files very little information was recorded pertaining to resident’s preferences for social/leisure activities. There was no evidence to indicate that the programme of activities had been devised with Rose Martha Care Centre DS0000015465.V336277.R01.S.doc Version 5.2 Page 15 residents and/or their representatives. On the day of the site visit no activities were observed to take place and interaction between some members of care staff and residents was observed to be very poor. Comments from residents were varied i.e. “there’s not much to do”, “same old thing” and “there’s activities occasionally”. One relative survey advised the following “I know staff are busy but residents sit around normally asleep” and “I take (my relative) out 3-4 times a week-sometimes more depending on how (they) feel. If I did not do this I don’t think (they) would ever go out”. Residents have access to their friends, relatives and other visitors who they wish to see at all times. There is little evidence that residents are empowered or encouraged to make decisions and/or choices. The resident’s minutes of the residents meeting held on 12.4.07 indicated that residents have spoken out about food/meals, laundry, medication systems and access to the garden. The Statement of Purpose states that residents are encouraged to become involved in the running of the care home, that they are consulted about staff appointments, staff training needs and any proposed changes to the care home. At the site visit there was little/no evidence to indicate that this happens in reality. The registered provider must demonstrate how the above can be enabled and to revise the Statement of Purpose as some elements are aspirational and fictitious. The home operates a four week rotating menu. On inspection, this was observed to be varied and indicated that residents can request a cooked breakfast and there are two choices of main meal at lunchtime and at teatime. Following discussions with the chef the inspector was advised that alternatives to the menu are available. On the day of the site visit inspectors observed both the lunchtime and teatime meals on the ground floor and first floor dining areas. Residents were observed to sit within the dining areas for some considerable time prior to the meal being served. Although the tables were laid i.e. tablecloths, placemats and cutlery, not all dining rooms were observed to have condiments. The hot meals provided to residents were sufficient in quantity, however the salads served to residents were very small. Support provided by some staff members to individual resident’s at meal times was observed to be apathetic and with little verbal interaction between staff and residents. One resident, was observed to be rushed with their meal by a staff member i.e. not waiting for the resident to swallow their food before putting another spoonful of food to their mouth, staff not monitoring how much food was actually eaten by individual residents and residents not being asked if they would like more. The above is in contrast to some good care practices seen throughout the day. Some members of staff expressed concern that the acting manager is insisting that all residents are to have their meals in the dining area and not in the lounge. This is unacceptable and residents must be given the opportunity to sit Rose Martha Care Centre DS0000015465.V336277.R01.S.doc Version 5.2 Page 16 and eat where they feel most comfortable. It is the registered providers responsibility to ensure that there are sufficient numbers of appropriate tables to enable those residents who wish to eat their meal in the lounge area or in their bedrooms to continue to do so. The staff training matrix indicates that only 65 of staff have attained up to date training pertaining to food hygiene. Rose Martha Care Centre DS0000015465.V336277.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 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a complaints policy and procedure, however there are deficiencies pertaining to the homes processes for recording complaints. There are adult protection policies and procedures evident but not all members of staff have undertaken appropriate training. EVIDENCE: The home has a complaints procedure and policy. The complaints procedure needs to be amended to reflect that the Commission for Social Care Inspection no longer has any statutory responsibility to investigate complaints. Any complaints received at the Commission will be referred back to the registered provider or to the local authority if they are contractually involved. As part of the inspection process inspectors will examine how the registered provider has dealt with issues and as to whether regulations are being met. From inspection of the homes complaints folder, the nature of the complaint was detailed, however in some circumstances there was no evidence to indicate following the investigation, details of the specific action take or outcomes identifying whether or not the complaint was substantiated or not substantiated. A monthly home audit was conducted by the previous registered manager on 26.2.07 and this detailed that the homes complaints management scored 100 . A further audit was undertaken on 18.4.07 by the deputy manager and the acting manager and this recorded a percentage of 87.5 . Rose Martha Care Centre DS0000015465.V336277.R01.S.doc Version 5.2 Page 18 No protection of vulnerable adults issues have been highlighted since the last inspection. On inspection of one care plan, this detailed that the resident exhibits inappropriate/aggressive behaviours on occasions. The care plan did not identify the specific nature of the aggression, known triggers or detail guidelines for staff as to how to provide proactive support with the resident. Additionally no risk assessment was devised. On inspection of the training matrix this details that 42 of staff had up to date adult protection training, however no staff members have received training pertaining to dealing with challenging behaviour. Rose Martha Care Centre DS0000015465.V336277.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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides an environment that meets the needs of those people who live at Rose Martha Care Centre. The home is comfortable and there is an on-going maintenance programme to improve the home. Some issues are evident pertaining to inadequate health and safety measures. EVIDENCE: On the day of the site visit, upon entry to the home slight odours were noted on the ground floor and strong odours were noted within the first floor corridors. Odours were observed to have dispersed by mid afternoon. Residents live in a homely and comfortable environment, which is reasonably well decorated, although some areas require redecoration. One relative survey forwarded to the Commission advised that some furniture needs to be upgraded. Rose Martha Care Centre DS0000015465.V336277.R01.S.doc Version 5.2 Page 20 On inspection of a random sample of resident’s bedrooms, all were observed to be personalised and individualised. Of those resident’s spoken with all were complimentary regarding their private space. Communal areas within the home were seen to be satisfactory. Two health and safety issues were highlighted during the site visit pertaining to the sluice on the ground floor not being locked and COSHH (Control of Substances Hazardous to Health) items being easily accessible and the laundry room not and cupboard under the sink not being locked and COSHH items easily accessible. The homes laundry room was observed to be tidy, well organised and clean. One relative survey forwarded to the Commission advised that laundry instructions for their member of family are sometimes ignored by care staff and items of clothing have disappeared, one of which is alleged to have been a birthday present. Rose Martha Care Centre DS0000015465.V336277.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 poor. This judgement has been made using available evidence including a visit to this service. Staffing levels do not always meet the needs of those people living at Rose Martha Care Centre and this affects the health and welfare of residents. The homes recruitment procedures are not robust and there are shortfalls, which do not adequately protect residents from harm or potential abuse. EVIDENCE: The deputy manager advised inspectors that staffing levels at the home are 2x senior staff and 9x care staff between 07.00 a.m. and 15.00 p.m. and then 2x senior staff and 8x care staff between 14.30 p.m. and 20.30 p.m. and 5x waking night staff. On inspection of five weeks staff rosters there was evidence to indicate that on occasions the above staffing levels had not been maintained both during the day and at night. The Commission has not received a Regulation 37 Notification advising that staffing levels have fallen and there was no evidence to indicate what measures were taken to address the shortfall. Staff rosters indicated that several members of staff are consistently working excessive hours i.e. 63-75.5 hours per week. A number of entries on the staff rosters indicate that staff are absent and it is not clear whether staff are actually absent or if they have changed duties with other staff. Since the acting manager’s appointment some members of staff have left the homes employment, whilst 2x senior members of night staff have been moved Rose Martha Care Centre DS0000015465.V336277.R01.S.doc Version 5.2 Page 22 onto day duties as a result of poor care practices, however they have not undertaken any day shifts as a result of the changes (On inspection of their staff files there is no evidence to indicate the rationale behind the decision, no evidence of any supervision or training needs identified). The acting manager’s actions have resulted in staff having to undertake additional shifts and work excessive hours and the deputy manager having to try and secure permission from the Operations Manager to utilise agency staff. As a result of shortfalls relating to ancillary staff, care staff are having to undertake laundry duties. Current staff vacancies include 1x activities co-ordinator (30 hours), 68 hours for laundry, 6x `bank staff`, 1x full time chef, 2x kitchen assistants, 1x night senior care and 1x night carer. No recruitment file/records were available for the acting manager. The Commission is aware that Southern Cross Healthcare have a centralised HR Department and that the files for manager’s are located within. However in order to comply with Regulation 19 and Schedule 4 of the Care Homes Regulations a pro forma must be completed detailing the persons name, address, qualifications/experience, date commenced at the home/date ceased, job title, contracted hours, other personnel issues held centrally (grievance/disciplinary action/medical issues) and verification and dates pertaining to references, criminal record bureau/POVA 1st checks, proof of identity, details of registration with a professional body, full employment history, reasons for leaving previous employment and a record of training including induction. On inspection of 6 random staff employment files, not all records as required by regulation had been sought. Identified shortfalls were noted in relation to reasons for leaving previous employment not explored, written references not always from the applicants last/current employer, no evidence of a criminal record bureau check/POVA 1st check for one person, gaps in employment not fully explored and it was unclear as to one persons eligibility to remain in the UK. In addition to the above, a further 3 staff files were examined. There was no evidence to indicate that the care manager/deputy manager received any kind of induction to her new role once the previous registered manager left the homes employment on 16th March 2007. On inspection of the employment file of the senior carer who was suspended on 22.4.07, no records were available pertaining to the rationale for the suspension etc. On inspection of the homes staff training matrix, this evidenced that 79 of staff have attained Manual Handling, 67 have undertaken Health and Safety, 65 of staff have Food Hygiene, 42 have Adult Protection, 24x staff have not received Fire Awareness, 31x staff have not undertaken First Aid and only 3x staff have received training pertaining to Infection Control. Very few staff have received training relating to Care Planning, Pressure Area Care, Continence, Nutrition, COSHH, Record Keeping and Challenging Behaviour. The Rose Martha Care Centre DS0000015465.V336277.R01.S.doc Version 5.2 Page 23 majority of staff have undertaken training relating to communication and 63 only have received training pertaining to Dementia Awareness. The monthly home audit conducted by the deputy manager and acting manager on 18.4.07 detailed 16 staff have NVQ Level 2, 10 staff are currently undertaking NVQ Level 2 and 1 member of staff is undertaking NVQ Level 3. Rose Martha Care Centre DS0000015465.V336277.R01.S.doc Version 5.2 Page 24 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, 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 acting manager has the required qualification and experience to manage the care home, however evidence suggests that prior to his appointment the home has not been well run or managed. EVIDENCE: The acting manager has only been in post since the beginning of April 2007, and the issues of concern highlighted throughout this inspection report are not reflective of his management and practices. Evidence at the site visit suggested that the care manager had day-to-day responsibility for the care home at the time of the previous registered manager’s period of absence and subsequent resignation of her post, however evidence suggests that she was given insufficient support from the registered provider, there was a serious lack of monitoring the running of the home and no induction to the new role. Rose Martha Care Centre DS0000015465.V336277.R01.S.doc Version 5.2 Page 25 The latter is seen as poor practice and evidences adverse impact on the level of care provided to individual residents. No evidence was available within the home to indicate that from December 2006, validation audits by the operations manager had been undertaken. At the time of the site visit the acting manager was on annual leave and the home’s operations manager was unable to undertake feedback of the inspector’s findings. A meeting was held on the 1st May 2007 between the Commission, the acting manager and the operations manager of Southern Cross Healthcare. Detailed feedback was given outlining both positive comments and issues of concern/deficits to meeting regulatory requirements. At the above meeting the inspector was able to discuss with the acting manager their qualifications and previous experience. It is evident that the acting manager has vast experience in working both within a residential care home setting and within a healthcare resource at a senior/managerial level. The acting manager advised that he has attained NVQ Level 3 and 4 and is due to complete the Registered Managers Award shortly. It is evident throughout discussions that the acting manager is keen to address identified shortfalls and has a `vision` for the homes future i.e. unitising the home and enabling a core team of staff to work within each unit. The acting manager recognises that this may take time (6-12 months) in order to reap the benefits. On inspection of supervision records for staff, it was evident that the majority of staff had not received supervision since December 2006 and 12x staff were observed to have had supervision in October 2006. Records indicated that supervisions due in February 2007 were not undertaken for both care staff and ancillary staff. The monthly home audit undertaken by the deputy manager and acting manager in April 07, details that 50 of care staff had received supervision. A random sample of records as required by regulation were inspected pertaining to safe working practices. Records evidence that there is a fire risk assessment for the home, that the homes fire systems are tested weekly, fire drills are undertaken regularly and fire equipment was last serviced in August 2006. Monthly checks were observed to be undertaken for the homes emergency lighting and alarms. Both of the homes gas safety and electrical installation certificates were deemed appropriate. At the time of the site visit the passenger lift certificate was not available, however this has since been forwarded to the Commission and seen to be satisfactory. The home has a quality assurance system in place. Inspectors were advised that a survey to seek people’s views were undertaken in 2006. No evidence of the outcome of the surveys was available. Rose Martha Care Centre DS0000015465.V336277.R01.S.doc Version 5.2 Page 26 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 1 X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 1 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 X X X 1 X 3 Rose Martha Care Centre DS0000015465.V336277.R01.S.doc Version 5.2 Page 27 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 OP1 Regulation 4 and 5 Requirement Timescale for action 01/07/07 2. OP3 14 3. OP7 15(1) The registered person must ensure that the Statement of Purpose and Service Users Guide is reviewed and updated to reflect the homes philosophy, objectives and services provided. The registered person must 14/06/07 ensure that all prospective residents are assessed prior to admission and that the registered person has confirmed in writing that it can meet the residents needs. The registered person must 14/06/07 ensure that all residents have a plan of care and these are detailed and comprehensive. Previous timescale of 7.12.05 and 1.7.06 not met. The registered person must ensure that risks to residents are identified and as far as possible eliminated. Previous timescale of 7.12.05 and 1.7.06 not met. The registered person must ensure that all care plans are DS0000015465.V336277.R01.S.doc 4. OP7 13(4) 14/06/07 5. OP7 15(1) 14/06/07 Rose Martha Care Centre Version 5.2 Page 28 6. OP12 16(2)(m) and (n) devised in consultation with the resident and/or their representative. The registered person must ensure that all residents receive/have the opportunity to participate in an activity programme which meets their specific needs. 01/07/07 7. OP14 12(2) 8. OP15 16(2)(i) Previous timescale of 1.1.06 and 1.7.06 not met. The registered person must 14/06/07 ensure that residents are enabled to make decisions and choices in respect to their care, health and welfare. The registered person must 14/06/07 ensure that all residents receive adequate quantities of food at all times and that they know what is on offer at mealtimes. Previous timescale of 1.6.06 not met. The registered person must ensure that staff working at the care home receive training relating to POVA and dealing with peoples aggression. The registered person must ensure that all areas of the home are free from hazards and risks to the health and safety of residents. This refers specifically to COSHH items being easily accessible and the sluice and laundry rooms not being locked. The registered person must ensure that there are sufficient numbers of staff on duty at all times which meet the numbers and needs of residents. The registered person must ensure that all records as required are available and that robust recruitment procedures are adopted and adhered to at DS0000015465.V336277.R01.S.doc 9. OP18 13(6) 01/09/07 10. OP19 13(4)(a) and (c) 14/06/07 11. OP27 18(1)(a) 14/06/07 12. OP29 19 14/06/07 Rose Martha Care Centre Version 5.2 Page 29 13. OP30 18(1)(c) and(i) 14. OP31 10(1) 15. OP36 18(2)(a) all times. This includes ensuring that the manager’s file is available for inspection. The registered person must ensure that all staff working at the care home have appropriate training to the work they perform and have received a structured induction. The registered provider must manage the care home with sufficient care, competence and skill. The registered person must ensure that all staff working at the care home are appropriately supervised. 14/06/07 14/06/07 14/06/07 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. 2. 3. 4. 5. Refer to Standard OP7 OP10 OP14 OP15 OP28 Good Practice Recommendations As part of good practice procedures, daily care records should be written daily and after each shift. Records should also include action taken by staff and outcomes. Ensure that information relating to end of life issues and terminal care are recorded. Ensure that care staff interact with residents in an appropriate manner. Ensure that service users are not rushed and hurried at meal times and that this is a pleasant experience. Ensure that staff do not work excessive hours. Rose Martha Care Centre DS0000015465.V336277.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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.V336277.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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