Inspection on 12/07/07 for Marlborough Court Care Centre

This inspection was carried out on 12th July 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Marlborough Court Care Centre 30/05/08

Marlborough Court Care Centre 22/12/06

Marlborough Court Care Centre 08/06/06

Marlborough Court Care Centre 08/11/05

Marlborough Court Care Centre 10/05/05

Marlborough Court Care Centre 17/01/05

Marlborough Court Care Centre 13/07/04

Marlborough Court Care Centre 08/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Marlborough Court Care Centre 7 Copperfield Rd Thamesmead London SE28 8RB Lead Inspector Keith Izzard Unannounced Inspection 12th July 2007 09:30 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 Marlborough Court Care Centre DS0000006766.V340444.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. Marlborough Court Care Centre DS0000006766.V340444.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marlborough Court Care Centre Address 7 Copperfield Rd Thamesmead London SE28 8RB 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) 020 8310 8881 020 8310 7767 marlborough.court@ashbourne.co.uk Exceler Healthcare Services Leasing Limited vacant post Care Home 78 Category(ies) of Dementia (28), Old age, not falling within any registration, with number other category (50) of places Marlborough Court Care Centre DS0000006766.V340444.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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 residential care of old people Date of last inspection 22nd December 2006 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 conventional nursing care, 27 single bedrooms for older people with dementia on the first floor and 29 single bedrooms for older people requiring conventional personal residential care on the second floor. All of the rooms have en-suite facilities. Each unit has a separate dining room, two lounges, toilets and three bathrooms. A 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 DS0000006766.V340444.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed in nine hours by two Inspectors on 12/07/07. The previous full inspection was an unannounced inspection on 22/12/06. The inspection included a complete tour of the premises, examination of individual resident care records and other documentary evidence of health and safety recording. During this time discussions took place with a number of residents and staff members. Prior to the inspection survey questionnaires were sent by the Inspectors to a larger number of residents, relatives and involved external professionals with the home. A detailed pre-inspection questionnaire was submitted, as required to the CSCI by the manager prior to the inspection and the Inspector referred to records maintained by CSCI since the previous inspection. Four resident care plans were case tracked and the personnel files of four staff members recently employed were examined in respect of the recruitment practice of the home. Overall, practice was found to be of a good standard and fifteen questionnaire responses that had been received at the time of writing this report were predominantly complimentary of the service provided. Two relatives commented that they felt more care staff should be employed and one thought bathrooms and toilets should be refurbished. Some residents commented that there should be activities provided at weekends. One resident would like the chef to make more stew dumplings. Since the appointment of the new manager it was noted that good efforts had been made to address all the requirements made at the previous inspection. From observations made, and reports received from various outside professionals, residents, relatives and staff members, the manager has instituted a number of changes that should benefit resident care. It was pleasing to note that staff members’ morale has been raised and all those spoken to praised the overall improvement in the home. What the service does well: All areas of the building were seen and were clean and free from unpleasant odour. Residents commented that the standard of cleanliness in the home was good. It was evident that service users had been given the opportunity to bring in personal possessions to personalise their bedrooms and overall a homely appearance had been created following efforts that had been made to hang pictures in communal areas and provide better signing on the dementia Marlborough Court Care Centre DS0000006766.V340444.R01.S.doc Version 5.2 Page 6 unit. Maintenance and Health and Safety matters had been attended to in accordance with the Standards. Residents were seen to be comfortable and good interaction was observed between staff and service users. Residents were seen to be appropriately dressed for the very warm weather and well cared for in clean laundered clothing. Residents and relatives commented that most staff members were caring and professional in their approach. What has improved since the last inspection? What they could do better: Eight requirements and five recommendations have been made within this report. One requirement reflected the need for the manager to now apply to be come the registered Manager for the home and another regarding recruitment documentation required. Three other requirements related to the admission process and risk assessments completed prior to installation of bedrails and follow up of any unexplained injuries that might occur to residents, for example falls not witnessed. A requirement was made in respect of medication procedure, the need for dementia training for staff members and a number of areas in the building requiring refurbishment, particularly one bathroom. Recommendations were made in relation to medication practice, the presentation of any pureed foods, providing activities for residents at weekends and lowering notice boards for the benefit of residents in wheelchairs. Marlborough Court Care Centre DS0000006766.V340444.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. Marlborough Court Care Centre DS0000006766.V340444.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 Marlborough Court Care Centre DS0000006766.V340444.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): 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Documentation relating to pre admission assessments and the admission process are available on all service user care files and retained on the relevant unit. All residents including short- term residents must be assured their needs can be met by the home prior to their moving or within five days if they are admitted in an emergency. EVIDENCE: Standard 3 Pre-admission or care manager assessments were seen on the four care plans viewed. Three residents had received written confirmation that based on Marlborough Court Care Centre DS0000006766.V340444.R01.S.doc Version 5.2 Page 10 assessment the home was suited to meeting their needs, one that was an emergency admission had not and should have been received this within five days of admission. All emergency and respite care admissions must be admitted to the same standards as long -term admissions. See Requirement 1 Many of the residents on the nursing unit had a diagnosis of dementia. As the service is not registered to provide dementia care on the nursing unit management must ensure they consider the needs of all residents and skills of staff when admitting residents, see Standard 30. See Requirement 6 Standard 6 This key standard was not assessed, as the home does not provide an intermediate care service. Marlborough Court Care Centre DS0000006766.V340444.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 &10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans examined were comprehensive and well recorded. Health care needs were appropriately attended to and recorded on residents care files. Medication was generally well managed but a requirement was made regarding the management of homely remedies. Residents were treated with respect and their dignity maintained. EVIDENCE: Standard 7 Two care plans were viewed on the nursing unit. And one on each of the conventional care and dementia care units. Care plans were comprehensive, Marlborough Court Care Centre DS0000006766.V340444.R01.S.doc Version 5.2 Page 12 well written, up to date and kept under review. Care plans were based on assessment and showed how resident’s identified needs were to be met. One resident had bedrails fitted but a risk assessment had not been prepared in relation to these. One resident had been reviewed the day before and it was recommended that the daily care notes should reflect the main outcomes of the meeting, pending receipt of the full minutes of the meeting from the community care, to facilitate clarity. One resident, case tracked, was unable to comment fully on the quality of care provided and the other three residents interviewed were satisfied with how care was provided in the home. See Requirement 2 & Recommendation 1 Standard 8 All residents were registered with a GP and supported to access other healthcare services. In the care plans viewed there was a record kept for contact with professionals. This showed that a GP, chiropodist and social workers had seen the residents. Staff said that where necessary the GP referred residents to other healthcare professionals such as a psychiatrist or community psychiatric nurse. A visiting GP stated to the Inspector that staff members were professional in their approach and that communication between them and the surgery had improved over the last year. Staff members were organised with relevant background information available on residents, when the GP visited to see residents. Standard 9 Medication management was assessed on the nursing and dementia care units. Both units had appropriate storage facilities and monitored room and fridge temperatures. Records were kept for receipt, administration and disposal of medicines. Records were kept so that an audit trail could be completed. Medicine records checked for four residents were correct. No controlled drugs were in use but safe systems were provided to store and record these, should this be necessary. None of the current residents managed their own medicines. Medication administration charts were well maintained and showed that prescribed medicines including topical applications were administered. Homely remedies were kept on the nursing unit and used for the whole home. These records were well maintained and accurate. Two issues noted were that the ground and first floor units had different homely remedy lists agreed with the GP and on the first floor the administration chart showed that one medicine for a resident had been stopped but it was not clear if or when the GP had done this. Other areas for improvement were discussed with management such as keeping a medicine profile for each resident, evidence of GP medicine reviews for individual residents, evidence to show that staff responsible for medicine management had been assessed as competent and a protocol for the administration of ‘as required’ pain relief for residents who cannot verbalise this need. See Requirement 3 & Recommendation 2 Marlborough Court Care Centre DS0000006766.V340444.R01.S.doc Version 5.2 Page 13 Standard 10 Residents spoken with said staff were polite, helpful and supportive. Staff members were observed interacting appropriately with residents. Care plans seen showed that resident preference was considered for example in relation to getting up and going to bed, choosing which clothes to wear and encouraging independence. Relatives seen also said that staff treated resident respectfully. Marlborough Court Care Centre DS0000006766.V340444.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): 12–15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Attention was generally paid to establishing and recording residents interests prior to their admission to the home. However, the input made by individual care staff and the activity coordinator does need to be quantified in a clear way to enable an accurate assessment of the level of activities provided for residents. Visitors are welcome at anytime, and are able to take part in the life of the home. A varied and nutritious diet is provided. EVIDENCE: Standard 12 Two activity organisers were employed. A programme of activities was provided and delivered flexibly based on resident’s daily preferences. Marlborough Court Care Centre DS0000006766.V340444.R01.S.doc Version 5.2 Page 15 Resident’s comments varied regarding the provision of activities. Some residents enjoyed these and participated regularly while others said they did not enjoy organised activities. Some residents said it would be nice to have activities at the weekend, as often this was a very quiet time in the home. Activity staff members maintained a diary to show what activities were provided and who attended and also kept individual resident records. Records for June 2007 showed that a variety of activities were provided on a regular basis for example bingo, musical bingo, quoits, quizzes and a number of residents enjoyed an outing to Southend and to Holly Tree farm. Staff had made a successful bid for Department of Health capital funding and planned to build a sensory garden. Work had commenced on this and raised herb beds were built. Staff said that where possible residents were involved with the planning and work on the garden. Plans also included the reintroduction of the aviary in the ground floor enclosed garden area. See Recommendation 3 Standard 13 There are additional rooms on all units to enable residents to meet with relatives in private in a room other than their bedroom. There is also access to a telephone to enable residents to make all receive calls in private. All of the residents bedrooms seen were individually personalised with personal effects, photos and mementos Standard 14 It was apparent that staff did promote some aspects of personal choice. A number of residents interviewed told the inspector that they were able to choose where and how they spent their time, were able to decline the offer to join activities or events if they did not want to attend and were asked about whether they wanted a bath or shower and what they wanted to wear. Standard 15 Lunch was observed on the nursing and dementia units. Tables were nicely laid for lunch and the daily menu provided; in pictorial form on the dementia unit. Residents had a choice of two main meals and if neither was suitable then alternatives were provided. Staff were attentive and assisted residents appropriately to enjoy their meal. Resident’s comments regarding food varied. Some said the food was very good and some said it was not so good. The pureed meal looked very unappetising and was served in large portions. A number of residents said they enjoyed their meal and some relatives who visited daily to assist their relative with their meal said the food was satisfactory. Marlborough Court Care Centre DS0000006766.V340444.R01.S.doc Version 5.2 Page 16 See Recommendation 4 It was noted that all residents on the nursing unit had daily food and fluid intake charts maintained. There was no evidence to show that these charts were being calculated or monitored appropriately. Using these forms routinely for every resident in this way was not seen as a good use of staff time or a benefit to the residents. Marlborough Court Care Centre DS0000006766.V340444.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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear complaint process readily available to residents, relatives and involved professionals and all can be confident that complaints will be investigated and acted upon. The home has a Safeguarding Adults policy and procedure. Staff members have received training and displayed a good understanding in this area. EVIDENCE: Standard 16 The complaints procedure complies with The Care Homes Regulations 2001. Information about the contact details for the CSCI had been updated and there were timescales for staff to follow when investigating concerns. Guidance was provided about the stages that complainants could follow if they were not satisfied with the response provided by the home. No complaints had been received directly by CSCI and the complaints log retained within the home showed that since the previous inspection two complaints had been received, one of them was an allegation made about bruising to a resident referred to in Standard 18 below, the outcome of which has yet to be determined. The second was in relation to a cut finger suffered by a resident, the allegation was not substantiated but could not be finally concluded because of an overdue Marlborough Court Care Centre DS0000006766.V340444.R01.S.doc Version 5.2 Page 18 response from a relative of the resident. No complaints have been received by CSCI in relation to the home. Standard 18 Staff members that were interviewed by the Inspectors were aware of the procedure for reporting poor practice and abuse and were confident that senior staff would act to address any issues they raised. One issue in relation to safeguarding adults had arisen within the home since the previous inspection in December 2006. This was subject to an ongoing external investigation by a Senior Community Care manager. The initial evidence suggested that the home was not culpable however this has yet to be fully determined and the actual outcome will be reported on in the next inspection report for the home. The matter had been appropriately and promptly reported under Safeguarding Adults procedures to both the local authority and CSCI. Marlborough Court Care Centre DS0000006766.V340444.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall, the environment is clean and well maintained, however one bathroom needs re-commissioning and urgent attention to the replacement of one of the lifts. EVIDENCE: Standards 19 & 26 All three units were clean, tidy and free of offensive odours. Bedrooms and bathrooms were generally clean, tidy and well maintained. The following issues, however, require attention on the nursing unit; in bathroom 2 the bath panel must be fixed properly to the bath, a Perspex panel was fitted to the back wall of the shower cubicle and this needed to removed and the Marlborough Court Care Centre DS0000006766.V340444.R01.S.doc Version 5.2 Page 20 area cleaned, the shower room should be refurbished to make it a pleasant area for residents to use. In bedroom 17 the area behind the toilet pan needed cleaning and painting. Residents spoken with were satisfied with their environment and relatives said the home was kept clean. Hand washing facilities were provided in areas where waste was handled, bacterial hand gel was located in appropriate places round the unit and staff had access to adequate supplies of protective clothing. In bathroom 2 on the nursing unit vinyl gloves were seen in the waste bin. It was recommended to have resident information boards fixed lower down on the wall so people in wheelchairs can easily see them. One bathroom on the dementia care unit must also be re commissioned as soon as possible. See Requirement 4 & Recommendation 5 Standard 26 The home was generally clean pleasant and hygienic throughout. Marlborough Court Care Centre DS0000006766.V340444.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 – 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met within a safe environment. Dementia training is a priority for attention and some improvements are required in the recruitment process. EVIDENCE: Standard 27 The numbers of staff on duty were assessed against the rotas over a fourweek period and also the staffing notice in respect of the nursing unit. All units had adequate staffing for example, the nursing unit a trained nurse and four care assistants, as the unit accommodated 20 residents. However in the event of there being 21 residents another qualified nurse would be required. On the dementia care unit 1 senior care worker and 4 care workers am and pm, at night time; 1 senior and 2 care-workers. Standard 28 Marlborough Court Care Centre DS0000006766.V340444.R01.S.doc Version 5.2 Page 22 The home recruits care staff members that have already been trained in care up to NVQ 2, where possible and also supports staff in taking this qualification. The percentage of staff with this training was assessed at above the required minimum of 50 qualified to NVQ level 2, although the manager stated that the aim is to achieve 100 as soon as practicable. Standard 29 Four staff files were viewed. These showed that most but not all of the requirements of regulation were met. The following issues were noted; one file did not have a recent photograph of the employee, one file had only one reference, one file had two references which had not been verified as genuine and one file had one unverified reference and on one file for a trained nurse there was no evidence to show that the provider had checked they were registered with the nursing & midwifery council. See Requirement 5 Standard 30 The manager said that there had been a lapse in training lately and she was making this a priority area to address. None of the staff on the nursing unit had received training in dementia care despite the fact that a number of residents on the unit had a diagnosed dementia. The same was the case for staff on the dementia unit. Please see Standard 3. Staff said they had access to advice and support from the visiting community psychiatric nurse and the GP. Some staff interviewed confirmed that lately there had not been so much training, generally, however new staff had received training in moving & handling and fire safety instruction. Dementia training must be set up as a priority for staff on both the dementia and nursing units and a matrix of the overall training planned for the current year must be provided in writing to CSCI. See Requirement 6 Marlborough Court Care Centre DS0000006766.V340444.R01.S.doc Version 5.2 Page 23 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, & 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 managed by a manager respected by staff members and regarded as approachable by both residents and staff alike. A formal application to be the Registered Manager should now be submitted. The home ensures that relatives and service users are able to voice their opinions and contribute their views on the running of the home. The home is well maintained, and observes health and safety practices. EVIDENCE: Marlborough Court Care Centre DS0000006766.V340444.R01.S.doc Version 5.2 Page 24 Standard 31 The manager is very well qualified, experienced, and well suited to perform the tasks required as manager of the home. It was evident that both the residents and staff members interviewed felt positively about the manager and all stated she was very approachable, neither residents or staff members would hesitate to speak to her should they have any concerns regarding the running of the home or the welfare of residents. Six members of staff who were interviewed, commented that the manager has made significant improvements in the general running of the home and that staff morale has improved because of this. The manager stated that she intends to apply to the Commission to become the Registered Manager for the home. A requirement is made that the application be submitted as soon as is practicable. See Requirement 7 Standard 33 The home is subject to an external annual management audit by Southern Cross and two financial audits unannounced per annum. The home is visited regularly, on a monthly basis, and a report compiled on the conduct and running of the home as required, under Regulation 26. These reports have been made available to the CSCI and copies are retained within the home. The home is also monitored on a regular basis by the Commissioning unit from both the London Boroughs of Greenwich and Bexley Social Services Department and the subsequent reports of these visits are made available to CSCI. The last reports were both broadly positive. The home now has a good record of compliance in respect of both CSCI reports and those from the Boroughs, except, the repair needed to one of the lifts. The manager conducts a comprehensive monthly audit of the home and this is counter audited by a regional manager bi monthly. There is also a nursing audit conducted unannounced by regional nursing staff at least once a year. The manager reported that the last nursing audit was very positive and the monthly audits conducted by the manager were seen at this inspection by the Inspectors and found to be satisfactory. Standard 35 This Standard could not be assessed on this occasion owing to the absence of the homes administrator, however the home has been audited twice in the past year and the home has always met this Standard at previous inspections. The Inspector had no reason to suspect that the Standard would not have been met on this occasion. This standard will be assessed at the next inspection of the home. Standard 38 Marlborough Court Care Centre DS0000006766.V340444.R01.S.doc Version 5.2 Page 25 The standard of record keeping in relation to the various health and safety checks and records that are required to be maintained, was of a good standard and that the previous improvements made in this area had been sustained. Records relating to fire drills, testing of call points, bed rails and hoisting equipment inspections were examined and found to be comprehensive and consistent with the detailed checks recorded on the pre-inspection questionnaire provided by the manager. Accident records were viewed. The information provided on these forms must improve to ensure they accurately reflect the details of the accident. Where necessary residents staff ensured residents received appropriate care following an accident. Records showed that some residents sustained unexplained injuries or injuries when being moved or receiving care but there was no evidence to show if these had been investigated or any action taken to prevent a recurrence. See Requirement 8 Marlborough Court Care Centre DS0000006766.V340444.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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Marlborough Court Care Centre DS0000006766.V340444.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 (1) d Requirement The Registered Person must confirm in writing to all residents, including emergency and respite care admissions, that the home is suitable to meet their needs. The Registered Person must ensure that a risk assessment is completed prior to providing a resident with bedrails. The Registered Person must ensure that only one copy of the homely remedy list agreed with the GP must be provided and this must be reviewed yearly. The Registered Person must ensure all areas of the home are kept in a good state of repair. The unused bathroom on the dementia residential care unit must be upgraded and put back into use. The area in bedroom 17 behind the toilet pan must be cleaned and clinical waste (gloves), not placed in waste bins but disposed of correctly. The Registered Person must ensure that all information DS0000006766.V340444.R01.S.doc Timescale for action 01/09/07 2. OP7 13 01/09/07 3. OP9 13 (2) 01/09/07 4. OP19 23 & 13 01/11/07 5. OP29 19 01/09/07 Marlborough Court Care Centre Version 5.2 Page 28 6 OP30 19 (5) g 7 8 OP31 OP38 8 13 required within the recruitment process in accordance with this regulation is obtained. The Registered Person must 01/10/07 ensure that dementia training is provided for all staff, in particular, on the dementia care and nursing units. The training matrix for the current year 07/08 must be submitted, in writing to CSCI. The manager must now submit 01/11/07 an application to CSCI to become the Registered Manager. The Registered Person must 01/09/07 ensure that a system is in place to follow up unexplained injuries sustained by residents and action taken to prevent a recurrence. 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 When reviews of care are conducted the main points of the review should be recorded on the care file, pending the receipt of the official written minutes from the community care manager. The following should be implemented as good practice: A medicine profile should be maintained for each resident. To record evidence of GP medicine reviews for individual residents. To provide evidence to show that staff responsible for medicine management have been assessed as competent. To develop a protocol for the administration of ‘as required’ pain relief for residents who cannot verbalise this need. Consideration should be given to the provision of activities at weekends for residents. Catering staff should ensure foods are pureed separately DS0000006766.V340444.R01.S.doc Version 5.2 Page 29 2. OP9 3. 4. OP12 OP15 Marlborough Court Care Centre 5 OP19 and looks appetising when served. Consideration should be given to the lowering of notices for residents on walls being lowered to assist those who use wheelchairs to read them more easily. Marlborough Court Care Centre DS0000006766.V340444.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. 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