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Inspection on 10/05/05 for Marlborough Court Care Centre

Also see our care home review for Marlborough Court Care Centre for more information

This inspection was carried out on 10th May 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Social and leisure needs were appropriately met and suited the residents, the activities programme provided has been redesigned, in particular to meet the needs of residents on the EMI unit and the recommended extra staffing hours for activities to be provided. Meals were relaxed with residents being encouraged to express choice on the EMI unit and a congenial setting provided. Residents choose the time they wanted to go to bed and whether they participate in activities provided or not.

What has improved since the last inspection?

An assistant has been appointed to help the activities coordinator. Care plans and recording have improved although further improvements are required on the EMI unit.

CARE HOMES FOR OLDER PEOPLE Marlborough Court Care Centre 7 Copperfield Road Thamesmead London SE28 8RB Lead Inspector Keith Izzard Unannounced 10 May 2005 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 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. Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Marlborough Court Care Centre Address 7 Copperfield Road, Thamesmead, London SE28 8RB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8310 8881 020 8310 7767 Ashbourne Limited and Exceler Health Care Services Leasing Limited Mrs Patricia Holttum Care Home 77 Category(ies) of Dementia (27), Old age, not falling within any registration, with number other category (50). of places Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 10 beds for general nursing care of people aged 50-59 years. 11 beds for the general nursing care of people aged 60 years. 29 beds for the residental care of old people. 27 beds for elderly people with dementia. Date of last inspection 18 January 2005 Brief Description of the Service: Marlborough Court Care Centre is a purpose built, three-storey home situated in North Thamesmead overlooking the River Thames. The home consists of 21 single bedrooms on the ground floor for people requiring nursing care, 27 single bedrooms for older people with dementia on the first floor and 29 single bedrooms for older people requiring personal care on the second floor. All of the rooms have en-suite facilities. Each of the three units has a separate dining room, two lounges, toilets and three bathrooms. Separate laundry, kitchen and staff changing facilities are provided on site. Outdoor areas include a garden, patio area and an aviary at the front of the property. Visitors can park in the private car park in front of the home. Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a period of seven and a half hours from 10.00am to 5.30pm by two inspectors and was an unannounced inspection. The inspection focus was particularly on the first floor Dementia unit as there were several identified areas of concern arising from the previous inspection conducted on 18.02.05 to do with maintenance and health and safety procedures, training and supervision of staff members. A tour of both the first and second floors was undertaken to assess the standards in relation to the maintenance of the building, cleanliness infection control and health and safety. Seven care staff members were interviewed and discussed the residents for whom they are responsible. The Inspectors also spoke with eleven residents on an individual basis, who all reported contentment with the service provided. However, four mentioned that the food could be improved. Other people interviewed included the manager, the activities coordinator and two local authoriy care managers who were visiting the home on the day of inspection. Throughout the inspection observations were made of how care workers and domestic staff members were performing their respective tasks and the manner in which they related to residents. Detailed reference was made to the care files of residents whilst interviewing these staff members. What the service does well: Social and leisure needs were appropriately met and suited the residents, the activities programme provided has been redesigned, in particular to meet the needs of residents on the EMI unit and the recommended extra staffing hours for activities to be provided. Meals were relaxed with residents being encouraged to express choice on the EMI unit and a congenial setting provided. Residents choose the time they wanted to go to bed and whether they participate in activities provided or not. Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Both inspectors have been concerned at the number of issues to do with maintenance and health and safety that have emerged over the past two inspections. Requirements have been made that these areas must be properly recorded scheduled for inspection and remedied as soon as possible. An audit must be conducted on the safety and security of widows throughout residents’ personal rooms, bathrooms and communal facilities. Moving and handling equipment must be inspected / serviced every six moths and an additional hoist provided on the EMI unit. Care staff members require updated training in moving and handling annually. All care staff must be made aware of the requirement to report significant accidents and incidents in the home to the CSCI within 24 hours. The complaints procedure for the home must be evaluated to ensure that complainants have confidence that their complaints will be listened to and acted upon. A requirement was made regarding infection control procedures on the first floor and in response to a complaint made in respect of one resident’s room the home must ensure that tasks of cleaning are clearly specified and differentiated between care and domestic staff. Care staff require training in dementia care covering the importance of promoting the dignity of service users, explaining the needs of residents and completing life histories to gain insight into their needs. Requirements were made in relation to more training for staff members and that regular supervision must be provided. An annual survey of the views of residents, relatives and visiting professionals must be conducted and the results published. Please contact the provider for advice of actions taken in response to this Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 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 standard(s) 3,4. A senior member of staff undertakes a formal assessment of residents needs prior to admission. The assessment included assessing residents health and welfare needs and judging whether there were any particular safety issues such as a history of falls. The home confirms the arrangements for admission in writing and provides information about the care and facilities provided prior to admission. The letter sent to prospective residents did not appear to confirm that the home was able to meet the individual’s needs in respect of health and welfare. The administrator agreed to review this issue with the Registered Manager. Some progress had been made on this unit to improve care practices and communication but further work is required. EVIDENCE: The home provides care and accommodation for up to 27 residents with dementia on the first floor unit. Some progress had been made on this unit to improve care practices and communication but further work is required. The introduction of key workers had led some staff members to seek more information from relatives about residents past life history and interests. This information should be recorded and shared amongst staff so that a more person centred approach to care can be achieved. Some of the staff on the Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 Page 10 first floor unit lacked a basic understanding of dementia and were seen restricting residents movements, for example, wandering around the corridors. Other staff members had received little dementia training but appeared to communicate effectively with residents and understood why residents with dementia may become agitated or aggressive. The previous recommendation to provide additional dementia training for the staff that are employed on the first floor unit had not been implemented. Requirements: 1 & 2. Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10 There was evidence that record keeping on the first floor unit had improved since the last inspection but further work is required to meet the minimum standard. The second floor conventional care unit had maintained a good standard. Residents’ health care needs are fully met. The management of medication was assessed on the first floor unit and was found to be good. However, a complaint was logged on the day of inspection partly to do with medication. This related to two separate incidents of medication being found under a resident’s bed. Medication must be dealt with in accordance with professional guidance and MAR sheets only signed when medication has been observed to have been taken. Care staff must ensure that the dignity of residents is promoted in respect of adequate and appropriate clothing and their appearance. EVIDENCE: Two sets of notes were examined on the first floor unit. Both of the residents had a variety of assessments and an up to date care plan. Some sections of the documentation such as risk management and life history were incomplete and plans provided little information about the individual needs of residents. The unit manager had asked senior carers to review and update documentation following discussion with residents relatives. Care plans were reviewed Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 Page 12 regularly. Four sets of notes were examined on the second floor unit and were found to be comprehensive and up to date. A local GP visits the home regularly and can be contacted in an emergency. Residents also had access to Chiropody, ophthalmology and dental services in the home and were supported to attend hospital appointments. Records of such appointments were seen on both the units inspected. Staff administering medication on the first floor unit supported residents who had difficulty understanding the need for medication and ensured that tablets were swallowed prior to leaving the resident. Storage facilities were good and the temperature in the medicine room was satisfactory. Accurate records were maintained of medication received into the home, administered and sent for disposal. There were no gaps on the two medication administration charts examined and the supply of medication corresponded with the records. A local procedure for the receipt, storage, administration and disposal of medicines had been developed but was still in draft at the time of the inspection. Controlled drugs were stored and recorded appropriately. One of the residents was prescribed medication to thin the blood. The medication chart included two separate entries relating to this prescription, one for the regular daily dose and one for a larger dose on Mondays and Fridays. There was no evidence that any errors had occurred but this arrangement could lead to errors if staff interpreted the instructions to mean that the resident required the regular daily dose and the increased dose on Mondays and Fridays. The unit manager agreed to discuss the matter with the pharmacist and amend the chart to reduce the risk of errors. The appearance of some service users on the first floor unit was dishevelled in respect of hair care and some female residents did not appear to be adequately provided with underwear. The hairdresser returned from sick leave on the day of the inspection and as a result a number of residents on the first floor unit looked more presentable by the time the inspectors departed. The majority of the residents were wearing footwear and staff members interviewed on both units expressed awareness of the need to maintain residents privacy when undertaking personal care. Requirements: 3,4,5. Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 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 standard(s) 12,13,14,15 Residents interviewed stated their satisfaction with their lifestyle within the home in relation to this group of Standards although several commented on negatively in respect of the food. However, it was difficult to identify specifics in relation to this and the home should conduct a survey in relation to resident’s opinions regarding food. EVIDENCE: On the second floor unit four residents confirmed that the lifestyle in their home matched their expectations and they were satisfied with the level of activities provided and that they had improved since the arrival of the new activities coordinator. On the second floor unit one resident was celebrating her birthday with four other residents and various other relatives and all were enjoying a take away meal. All four residents interviewed said that the home had an open door policy and that there were no restrictions imposed regarding maintenance of contact with friends, relatives or the community. Staff on the first floor unit had been instructed to ensure that residents were given a choice of food by plating up two different meals and allowing residents to pick the food of their choice. This is commendable. An adequate choice of hot food was provided at breakfast and lunchtime. A number of residents had white rice and potatoes with their main meal. A senior member of staff should supervise the serving of meals. Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 Page 14 Recommendation: 1. Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 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 standard(s) 16,18 The home needs to address the increasing number of complaints that have been sent either to the London Borough of Greenwich Contracts Unit or the CSCI direct, in recent months. There appears to be an increasing lack of confidence in the responses made by the home, or confidence that complaints will be listened to and acted upon within its own complaints procedure. The home must ensure that all staff members understand the need to record all accidents/ incidents and that significant events affecting the welfare of residents are reported to The CSCI under regulation 37 notifications within 24 hours. The implementation of adult protection must also be considered for any injuries that are unexplained. EVIDENCE: Three complaints have been made to the CSCI and the London Borough of Greenwich very recently, resulting from dissatisfaction with the responses made by the home within its own complaints procedure. These complaints are currently being investigated and the outcomes will be reported on in the next inspection report. One of the residents on the first floor unit had bruising below her left eye. There was no written record of this injury in the residents file and the unit manager could not explain how she sustained the injury. It was noted that the resident had bruising on other parts of her body on admission and was taking medication that may make her more at risk of bruising. Staff must ensure that all injuries to residents are documented and investigated promptly and consideration given to implementing adult protection procedures for those that are unexplained. Another incident regarding a serious fall suffered by a resident had not been notified to the CSCI. A third complaint was being investigated on the day of inspection to do with poor cleanliness of a service user bedroom, mislaid medication (Two incidents of tablets found under the Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 Page 16 bed), room still not being cleaned properly despite the housekeeper being called. Also fall not being notified to a relative and a hospital appointment being forgotten despite the daughter reminding the staff and referral to a GP regarding a bruised hand. These incidents were substantiated and upheld. Requirements: 6,7. Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,25,26 A number of outstanding maintenance issues that may impact on resident’s safety were observed on the first floor unit. Ongoing maintenance and health and safety issues featured heavily in the previous inspection report and whilst these were attended to, a previous recommendation that that the system for reviewing and monitoring these areas is reviewed, appears not to have been responded to. The maintenance log for the home is poorly maintained and must be improved to demonstrate that items are reported and checked/ monitored and dated. The home should appoint a permanent maintenance/ handyman/ at the earliest opportunity. Further items are the subject of requirements arising from this inspection in Standard 38. Residents on both units inspected had access to a variety of communal lounges and dining areas in reasonable condition, as were the facilities for bathing and toilets. However, it was noted that a previously substantiated complaint about the poor cleanliness of one resident’s bedroom notified to the Inspector on the day of inspection and upheld by the manager. The home must clarify the roles of care staff and domestic staff in terms of what their specific responsibilities are for cleanliness, as confusion appears to have been at the core of the issue. Infection control procedures must be observed and implemented in the sluice room on the first floor. EVIDENCE: Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 Page 18 Several window catches, handles and restrictors were broken or missing. The Registered Manager agreed to ensure that the two most urgent issues the broken / missing restrictors in room 23 and the bathroom opposite room 47 were addressed within 24 hours. A full audit should be carried out to ensure that all of the windows open and close properly and are restricted. The paintwork in the corridors and lounges was chipped and worn. Some of the signs and pictures to assist residents to locate their room, the bathrooms and toilets were poorly positioned above eye level. On the first floor unit a collage about Britain from the 1930s was displayed and new sofas had been purchased for the small lounge. The portable television in the small lounge was rather small. Staff should consider replacing the television with a larger screen to assist service users with impaired vision. Both the first and second floor units were clean and tidy and there were no unpleasant odours. Some of the soap and paper hand towel dispensers were empty. In the sluice room there were several piles of soiled laundry and used incontinence products placed directly on the floor, this was unacceptable. Staff said they had access to laundry and clinical waste bags but had not collected them from the central store. A complaint in respect of lack of cleanliness in the room of one service was upheld on the day of inspection. Requirements: 8,9. & Recommendations: 2,3. Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 The Inspectors were of the opinion that a full-time manager is required on this unit to ensure that staff members are adequately supervised and consistent leadership provided. The records of training had improved since the previous inspection. Moving and handling training must be updated annually and foundation training provided. EVIDENCE: At the time of this inspection staffing requirements were met on the second floor and there were five staff on duty on the first floor unit, one of whom was the unit manager. The unit manager currently works 18 hours each week on the unit and is employed as a training coordinator for 12 hours each week. Senior staff members are now responsible for acting as key workers and some staff had made a point of establishing links with residents’ families. The unit manager was uncertain whether there were any staff vacancies on the first floor unit but said that the current establishment does provide adequate cover for staff annual leave. The home employs two training coordinators who were responsible for facilitating and organising staff training. This included induction, statutory and NVQ training. The records of training had improved and an individual record of all training undertaken by staff was maintained. The files examined indicated that staff had access to relevant training but there was no evidence of foundation training and some staff had not received moving and handling training for almost two years. The homes moving and handling trainers Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 Page 20 require a training update in order to be able to facilitate further moving and handling training. Requirements: 10,11,12. Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,36,38 The home must implement an annual survey of the views of professionals on the running of the home and publish the results. Similarly the views of service users must be regularly reviewed and residents meetings conducted on a regular basis. There was no evidence that staff on either units on the first and second floor were receiving formal supervision; this was subject of a restated recommendation at the previous inspection and is now a requirement that must be complied with. The responsibility for who supervises staff requires clarification within job descriptions and supervision training provided for those who undertake this task. As noted previously the home must ensure that all significant events in the home are notified under Regulation 37 to the CSCI. EVIDENCE: The home relies on comment cards placed in the foyer area for visitors to give their views on the running of the home, this needs to be formalised and the Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 Page 22 results published. Similarly it was noted that meetings for service users were behind schedule and must be organised regularly. Staff members had still not received the supervision required and there was a lack of clarity as to whom had the responsibility for supervision and to whom. Requirements:13,14,15,16 & Recommendation: 5. Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x 1 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 1 x x x x x x 2 STAFFING Standard No Score 27 2 28 1 29 x 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x 2 x x 2 x x 1 x 1 Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 Page 24 yes Are there any outstanding requirements from the last inspection? 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 4 Regulation 14 Requirement Following assessment residents must be provided with a letter confirming that their care needs can be met by the home. Training in dementia care and communication of residents needs must be provided for staff on the EMI unit. A more person centred approach must be developed by staff. Risk management, life histories and the individual needs of residents must be recorded. Medication must be dealt with in accordance with professional guidance and signed for on MAR sheets, only, after having been seen to be taken. Care staff must ensure that the dignity and respect of service users is maintained at all times. The complaints response procedure must be evaluated in order to ensure that complainants have confidence that their complaints will be listened to and acted upon. All care staff must be made aware of the requirement to report all significant events within the care home to the CSCI G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Timescale for action 1.08.05 2. 4 18 1.09.05 3. 4. 7 9 15 13 1.09.05 1.07.05 5. 6. 10 16 12 17 1.07.05 1.08.05 7. 18 & 28 37 1.08.05 Marlborough Court Care Centre Version 1.30 Page 25 within 24 hours. 8. 19 23 The ongoing maintenance and health and safety checks required in the home must must be properly recorded, scheduled for attention and implemented. Infection contol procedures must be implemented fully in the sluice room on the first floor. All parts of the home must be clean and free of odour The respective tasks of care staff and domestic staff regarding cleaning must be clarified. A permanent full time unit leader must be appointed on the EMI unit to ensure continuity and leadership for staff members. All care staff members must be annually updated in moving and handling training and trainers must be trained to provide this. All care staff must receive foundation training. The home must implement an annual survey of views of residents, relatives and visiting professionals regarding the service provided by the home. The results must be published and made available to the CSCI. Care staff must receive at least the minimum of six formal supervision sessions per year. Clarification must be made in respect of who provides supervision and that these individuals are trained to provide it. A full audit must be conducted of the window catches, handles and presence of window restrictors, throughout the building. All moving and handling equipment must be inspected /serviced every six mothsand stickers applied to evidence this. G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc 1.07.05 9. 26 13 1.07.05 10. 27 18 1.09.05 11. 28 18 1.09.05 12. 13. 30 33 18 24 1.09.05 1.09.05 14. 36 18 1.09.05 15. 38 23 1.08.05 16. 22 & 38 23 1.08.05 Marlborough Court Care Centre Version 1.30 Page 26 An oxford hoist must be provided for one service user on the first floor unit. This is a restated requirement. (not met within previous timescale 1.03.05). 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 15 19 19 19 38 Good Practice Recommendations A survey of residents opinions regarding the provision of food should be undertaken as soon as possibble. A maintenance person should be appointed on a full time basis as soon as possible, to ensure the safety and comfort of residents is maintained. Signs and and pictures to assist residents find their rooms should be located at eye level A larger TV should be considered on the EMI unit to assist those residents who have sight impairment. A full audit of what areas require redcoration and renovation should be undertaken as soon as possible. Marlborough Court Care Centre G51-G01 S6766 Marlborough V225546 10-05-05 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Sidcup Area Office River House 1 Maidstone Road, Sidcup Kent, DA14 5RH 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. 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