Inspection on 27/04/06 for Rose Martha Care Centre

This inspection was carried out on 27th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 23/04/07

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 27th April 2006 08:30 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 Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 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.V292296.R01.S.doc Version 5.1 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 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.V292296.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 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). The Registered Manager to undertake additional dementia training, which enables her to cascade training to all members of the staff team at Rose Martha Court, within three months. (by 22nd March 2005). 18th October 2005 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 within the homes Pre Inspection Questionnaire (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.V292296.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced `key` site visit whereby all key standards were inspected. The visit was carried out by two inspectors, Michelle Love and Carolyn Delaney. The site visit commenced at 09.00 a.m. and finished at approximately 20.00 hours. At this visit a range of records pertaining to individual residents and care staff were examined. In addition several residents and staff were spoken with. One relative and one visiting professional were spoken with and a number of letters have been sent to residents’ relatives/representatives/professionals following this visit, to seek their views as to the care and support they receive at Rose Martha Care Centre. These views have not yet been incorporated into this draft report. Once information has been collated, a letter will be forwarded to the registered provider detailing a summary of comments made. Following the site visit to the care home, letters were forwarded to four resident’s next of kin and three visiting professionals, requesting comments relating to the quality of care provided at Rose Martha Court Care Centre. Of those responses received, it was positive to note that relatives commented that the quality of care provided was good. Relatives stated that they had received information about the home, i.e. Statement of Purpose/Service Users Guide and had been offered an opportunity to visit the home. Comments from visiting professionals indicated that staff within the home are co-operative and helpful and that they are able to see individual residents in private. The only negative comments were in relation to, on occasions, there being a strong odour of urine, high turnover of “junior carers”, some difficulties experienced at weekends relating to having great difficulty to speak to someone (telephones not answered) and on some occasions a relative not being able to gain entrance to the home and having to enter via the kitchen. What the service does well: Visitors to the home continue to be encouraged to visit their relative/friend and are always made to feel welcome. Residents can see there member of family/friends either in their bedroom or in the small lounge/conservatory area on the ground floor, providing this is not being used. The home is clean, tidy, homely and pleasantly decorated. There is an ongoing programme of redecoration within the home. This ensures that residents have a nice place in which to live. Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 Page 6 Since the last inspection, a new care planning format has been introduced for both those residents who receive respite and for those assessed as requiring permanent care. The formats are seen as comprehensive and if completed well will ensure that individual resident’s needs are recorded. What has improved since the last inspection? What they could do better: Although the home’s care planning processes/risk assessments were much improved, further work is required to ensure that individual care plans for residents are detailed and comprehensive and include all information relating to residents health, social, emotional and physical care needs. Risk assessments must be devised for all areas of assessed risk and include information depicting the nature of the risk and how this is to be managed so as to reduce the risk. The above will hopefully ensure that staff know, Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 Page 7 specifically the individual needs of residents and therefore care delivery should be to a high standard. The registered provider must ensure that issues relating to increasing the number of hours for activities for residents, is addressed as this has been outstanding and highlighted within several previous inspections to the care home. The number of hours provided is insufficient to meet the needs/numbers of current residents. Care must be taken to ensure that the needs of those residents who have complex needs and dementia are also met. If staffing levels are increased, this will ensure that more residents within the home receive and participate within a programme of meaningful stimulation/activities. Additionally activities should be provided both `in house` and within the local community. 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. Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 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.V292296.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes systems for assessing prospective residents ensures that residents needs are assessed so that the home can make an informed decision as to whether or not the home is suitable and the individuals needs can be met. Prospective residents and/or their representatives have the opportunity to visit the care home prior to admission. EVIDENCE: Since the last inspection the home’s Statement of Purpose and Service Users Guide has been reviewed and updated to reflect the change of Registered Provider and reduction in the numbers of residents admitted to the care home on `step down`. A copy of both documents has been submitted to the Commission. A random sample of four pre admission assessments, were inspected for those people receiving `step down` and those admitted as permanent residents’. It was positive to note that pre admission assessments were readily available and Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 Page 10 systems much better organised. Information recorded was observed to be detailed and informative. There was clear evidence detailing resident’s assessed needs. In addition to the pre admission assessment, information had been sought from individual resident’s placing authorities/local hospitals. Since the introduction of the new pre admission assessment format, formal assessments have been introduced and implemented pertaining to pressure sores, nutrition, continence, falls and manual handling. Each pre admission assessment detailed as to whether or not the prospective resident and/or their representative had been offered the opportunity to visit the care home prior to admission. Additionally it detailed as to whether or not the resident/relative had received a copy of the home’s brochure/Statement of Purpose. One senior member of staff stated that constraints have been placed whereby there is pressure to undertake the assessment process within a tight time frame i.e. complete an assessment within thirty minutes. The registered manager was advised that no pressure should be placed on staff to complete an assessment. An assessment should be completed as fully as possible and where necessary more than one visit to assess should be undertaken which will also enable the assessor to meet with those people involved with the prospective resident i.e. relatives/other professionals involved. The number of residents able to receive `step down` has been reduced from 13 to 5. The registered manager and senior members of staff advised that this has been very positive. Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning processes within the home are much improved and detail resident’s health, personal and social care needs. The procedures and practices for the safe administration, receipt and disposal of medication at Rose Martha Care Centre are appropriate. EVIDENCE: On inspection of eight individual care plans and risk assessments, these were observed to be much improved in relation to the detail and general recording. There was clear evidence to indicate that relatives/representatives views had been sought and that wherever possible the care plan had been drawn up with the resident’s/relatives involvement. Although care plans were much improved, additional information is still required in some cases i.e. one person’s care plan made reference to them having a grade 1 pressure sore. No further information was recorded relating to the frequency of visits by the District Nurse, equipment required and treatment. Some care plans were noted to record very good detail relating to eating and drinking and personal hygiene, whilst others contained less detailed information. Of those care plans inspected the majority did not have a life story of the individual resident recorded. All Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 Page 12 formal assessments relating to pressure sores, manual handling, nutrition, continence and falls had been completed. Although manual handling assessments had been devised, additional information is required detailing the type of hoist/sling utilised by individual residents. Of those care plans inspected, all recorded information relating to residents and/or their representatives wishes pertaining to funeral arrangements/terminal care. Risk assessments were not available for all areas of assessed risk and/or need i.e. one residents care plan made reference to them being at risk of falls, however no formal risk assessment had been devised depicting the specific nature of the risk, factors to take into account and how to minimise the risk. Another resident’s care plan detailed that the individual wanders on occasions and their appetite is poor. No risk assessment was devised for either issue. Daily care records were seen to be more detailed and informative. However, on some occasions these were not written daily or after each shift. This is seen as poor practice and needs to be reviewed for the future. Staff who enter information within these records must ensure that entries also include action taken by staff and outcomes i.e. one entry made reference to the resident sustaining an injury to their genitalia without any further information depicting what action was taken by staff, if professional advice was sought and the outcomes. No information was noted within the resident’s record of multidisciplinary contacts. Interaction between care staff and individual resident’s was observed throughout the site visit. Some staff were noted to interact more positively with resident’s and naturally than others. All lounge areas were observed to be staffed and resident’s appeared happier and more animated than on previous visits. Medication administration procedures were observed both in the morning and at teatime. Procedures were seen to be appropriate and in line with regulatory requirements. No omissions of staff signatures were observed on the homes medication administration records. Of those residents who self-administer their medication (topical creams and bronchodilator inhalers) risk assessments were devised and kept under regular review. It was positive to note, that the issues which were identified at the last visit, had been addressed at this time. Records indicate that all senior staff who administer medication have received recent training in respect of the handling and administration of medicines. Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 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 and 15 Quality in this outcome area is poor. These judgements have been made using available evidence including a visit to this service. There is a programme of activities for residents’, which includes `in house` and external provision. Activities for those people with complex needs/dementia remain somewhat limited. In relation to food provided at the care home for residents, some elements of food delivery remain poor. EVIDENCE: A newly appointed activities co-ordinator commenced employment at the care home in February 2006. Currently there is only one activities co-ordinator for 37.5 hours per week (Monday to Friday) as the other person is on long-term sick leave. A record of activities undertaken by residents is recorded within individual folders by the co-ordinator. Activities include sensory boxes, fidget boards, reminiscence, games i.e. frustration, marbles, cards, dominoes, community activities (boules/bowls and visits to Southchurch Park). In addition to the above, external entertainment has been provided at the care home e.g. pantomimes, harpist, themed parties and film evenings. The activities coordinator has arranged for a gardener to visit the care home and residents have assisted in the making/hanging of bird feeders in the garden. In the future the activities co-ordinator is looking to liase with local schools and to get them providing assistance in the making of sensory boxes and providing Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 Page 14 entertainment within the care home setting. The activities co-ordinator was keen, committed and passionate about wanting to improve residents’ recreational interests and personal preferences. It was positive to note that the home’s activities room on the first floor is being utilised on a daily basis. The number of hours set aside for activities within the care home remains inadequate for the needs and numbers of residents. This continues to be of concern and has been highlighted at previous inspections to the home. Some staff appear keen to assist residents in undertaking activities with residents, whilst others appear to lack insight, motivation and skill to undertake such tasks. Particular attention must be given to those residents who have complex/dementia needs as they have in the past been excluded and not received meaningful activities/stimulation. The home operates a four weekly menu. The menu was displayed in the main reception area and within lounge areas, however this did not match the meal served to residents on the day of the site visit by inspectors. The menu displayed was written in small print and the majority of residents spoken with could not say what was on the menu for the day’s meal. Improvement was noted within all but one lounge/dining area, whereby, residents were asked by care staff if they wished to have gravy with their meal. Condiments (salt and pepper) were readily available and placed on tables for residents so as to promote choice and independence. Some residents within one lounge on the first floor were observed to wait for up to 30 minutes for their lunchtime meal and some residents were overheard to comment about having to wait for so long a period. When questioned staff stated to the inspector that the reason for the wait was as a result of their being only heated trolley available for the first floor and that meals are served to those residents who require assistance first. Residents comments relating to food were not very complimentary and included “ that food is a disgrace”, “ sandwiches as usual I suppose” and “ there’s little choice and we always have sandwiches in the evening”. The provision of drinks for residents was not good. Although drinks are available throughout the day, these were not easily accessible to residents. Many residents need to rely on care staff to offer drinks, however staff did not appear to do this on a regular basis throughout the day of the site visit. The inspectors were advised that currently no residents require a liquidised/pureed diet, six residents are diet controlled diabetics and only three residents require assistance with feeding. Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 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 good. This judgement has been made using available evidence including a visit to this service. The home has an adequate complaints and adult protection policy and procedure in place. The systems in place for dealing with complaints/protection of vulnerable adults issues are appropriate and protect residents’. EVIDENCE: Since the last inspection the home has dealt with one protection of vulnerable adults issue and six complaints. Complaints received at Rose Martha Care Centre related to noise, equipment issues, poor food, care issues for one resident, financial discrepancies and a complaint from a GP. Except for the last complaint, which has not yet been addressed, all others have been dealt with appropriately. Records include the specific nature of the complaint, details of any investigation and any action taken. All but three members of staff within the home have received Resident Welfare training. The registered manager advised that currently no residents within the home exhibit challenging/inappropriate behaviours. Following discussions with some staff they were able to demonstrate a good understanding of protection of vulnerable adults procedures. Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment remains appropriate for the numbers and needs of residents, and provides residents with a homely and attractive place in which to live. EVIDENCE: The home continues to be well maintained and decorated for residents. There is currently a programme of redecoration taking place within Rose Martha Care Centre. All bedrooms inspected continue to be personalised and individualised for residents needs. On the day of the site visit , the home was observed to be clean and odour free. Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. Staffing levels are seen as appropriate, except for activities for residents. The home’s vetting and recruitment practices protect residents. There was evidence to indicate that staff working at the care home, receive both mandatory and specialist training. EVIDENCE: Minimum staffing levels as agreed with the previous registration authority are being maintained, except for the limited hours provided for the implementation of activities for residents. The deployment of staff within Rose Martha Care Centre is much improved and it was positive to note that lounge areas during the site visit were staffed at all times. Since the last visit, the registered manager has allocated staff to specific `units` when they arrive on duty so as to improve and maintain continuity of care. The staff roster indicates that some staff are still working excessive hours i.e.50 to 65 hours per week. Recruitment records for six members of staff were randomly sampled. Recruitment practices were noted to have improved and all records as required by regulation had been sought. New staff appointed were, observed to be supernumerary to the staff roster and were `shadowing` more senior staff/those with experience, as part of their induction. Staff training records evidenced that staff receive regular mandatory and specialist training. Following the last visit to the care home, the registered Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 Page 18 manager has forwarded on several occasions evidence of training undertaken by staff. Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 Page 19 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, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run and managed by an effective registered manager. Monetary records and accounts for residents are well organised and maintained and these clearly protect individual residents financial interests. EVIDENCE: There is clear evidence since the last visit to Rose Martha Care Centre, to indicate that the registered manager has worked very hard to improve standards of care at the home and to meet the regulatory requirements as identified within the last inspection report. Some negative comments were made by residents about the management of the home e.g. “she’s never here”, however there was no evidence to support this as the duty rota indicates that the registered manager has been present at the care home on a daily basis. Additionally there was some negativity noted when speaking with some Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 Page 20 members of care staff. It is believed that there is no basis for the negativity, however the registered manager has implemented many new systems and delegated some management responsibilities and accountability for day-to-day care delivery. There is good evidence to indicate that regular meetings for all members of staff and residents are undertaken. One very positive aspect is the implementation of `floor audits`, which depict evidence of the manager’s findings when `walking the floor` i.e. care needs of residents, cleanliness of the premises, health and safety issues and maintenance requirements. On inspection of several resident’s monetary records, these were seen to be satisfactory. The home’s accounting procedures were good and included a record of monies received, spent and balances. Receipts were readily available to evidence monies spent. A planned programme of supervision was evident for all staff. Actual staff supervision records were not inspected on this occasion as they noted to be sealed. A random sample of records as required by regulation were inspected during this site visit. Records related to the home’s passenger lift, fire equipment/fire alarms, hoists and slings, gas and electrical safety installation certificates, hot water temperatures, record of fire drills and employers liability certificate. All were seen to be satisfactory. Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 Page 21 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 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 X 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 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 3 3 X 3 3 X 3 Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 Page 22 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 The registered person must ensure that all care plans are detailed and comprehensive. (Previous timescale of 7.12.05 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 not met) The registered person must ensure that all residents receive/have the opportunity to participate in an activity programme which meets their specific needs. (Previous timescale of 1.1.06 not met) The registered person must ensure that there are sufficient hours set aside for the implementation of an activity programme for the numbers of residents. Timescale for action 01/07/06 2. OP7 13(4) 01/07/06 3. OP12 16(2)(m) and (n) 01/07/06 4. OP12 18(1)(a) 01/07/06 Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 Page 23 5. OP15 16(2)(i) and 12 (Previous timescale of 1.2.06 not met) The registered person must 01/06/06 ensure that all residents receive a varied choice of meals and that residents know what’s on offer. 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 OP7 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. Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Rose Martha Care Centre DS0000015465.V292296.R01.S.doc Version 5.1 Page 25 - 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. 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