Inspection on 30/05/08 for Marlborough Court Care Centre

This inspection was carried out on 30th May 2008.

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

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

Other inspections for this house

Marlborough Court Care Centre 12/07/07

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Marlborough Court Care Centre 7 Copperfield Rd Thamesmead London SE28 8RB Lead Inspector Keith Izzard Key Unannounced Inspection 10.00 30 May, 9th June & 4th July 2008 th 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 Marlborough Court Care Centre DS0000006766.V365039.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.V365039.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 marlboroughcourt@schealthcare.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.V365039.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing (CRH - N) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places: 50) 2. Dementia - Code DE (maximum number of places: 28) The maximum number of service users who can be accommodated is: 78 12th July 2007 Date of last inspection 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.V365039.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection key inspection took place over three separate days, on 30/05/08,09/06/08 and 04/07/08. Two inspectors undertook the first two days of the inspection and on the third day of inspection the Inspector was accompanied by a Regulation Manager on the inspection. Originally the second date was to have been the start date for this Inspection, however, due to a quality alert being raised by colleagues in Greenwich and Bexley Commissioning units an urgent visit was conducted on 30/05/08. This was largely in response to the sudden departure of the home’s chef because of illness and the subsequent arrangements made by Southern Cross management to provide appropriate and qualified alternative catering staffproved to be inadequate. This in turn was aggravated by the absence of the permanent manager who had been off sick herself and had then suddenly resigned. At the time of the inspection the home had no permanent manager and has been without a Registered Manager for three years following a succession of nine managers, either acting or permanent. The permanent managers either resigned or been dismissed and all four of them left prior to any application being made to apply to become the Registered Manager with the Commission. This has resulted in ongoing instability for both residents and staff members alike and it is essntial this continued disruption and lack of continuity be brought to an end. Fortunately, we are now able to confirm that a new manager has been appointed with a start date in mid July 2008. We expect that the manager will submit an application to CSCI to become the Registered Manager for the home promptly. The inspection process included a review of information held on the service file. This information was provided by two Commissioning Officers from both the Boroughs of Bexley and Greenwich, who had undertaken monitoring visits on a number of occasions surrounding the inspection dates. These provided invaluable assessments and monitoring information. Also included were care manager reviews conducted in response to concerns raised about care issues and two Safeguarding Adults Protection alerts. Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 6 On each of the three days of the inspection the premises were inspected, we talked to residents, staff and management.Records were examined regarding compliance with previous inspection requirements.Information provided about the home in relatives surveys conducted by LB Greenwich were also reviewed. Some of the feedback that we received is included in this report. We spoke to approximately fifteen residents and a similar number of staff together with four relatives over the course of the inspection. From these conversations the main cause for complaint for residents, relatives and staff members was the recent crisis situation regarding catering and cleaning within the home and a disrupted staffing situation, particularly, on the nursing unit. Also a number of residents, relatives and staff members were aware of the continued absence of the permanent manager but unaware of her resignation and expressed concern regarding the history of management difficulties the home has endured. A number of people also commented on the lack of management presence at the recent open day for the home attended by the Mayor to celebrate the tenth anniversary of the home opening and were surprised and disappointed that there was no management presence from Southern Cross. Over the three days of inspection we were assisted either by a neighbouring Southern Cross home manager or the Operations Manager from Southern Cross. The Deputy Manager and a Unit Manager from the Home also assisted on the first day of inspection, both of whom, subsequently resigned, prior to the completion of the inspection on the third day. Inevitably this inspection has had a central focus on the ongoing staffing and management difficulties and has sought by way of requirements and recommendations made, to ensure that some stability and continuity is provided for the residents and existing staff members in the future. What the service does well: What has improved since the last inspection? Four of the previous eight requirements had been complied with. One was no longer applicable and two have been restated within this report. Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 7 What they could do better: Fourteen requirements were made arising from this inspection. Two requirements and one recommendation were restated as they were not complied with following the previous report and as a result, in respect of the two requirements statutory notices will be applied for non-compliance. Other requirements were to do with improvements needed in care plans and recording. And also arising from shortfalls in recording and monitoring of health care needs and the administration of medication. The recording of complaints and the monitoring of accidents and incidents and the required notification to CSCI and placing authorities was incomplete necessitated the making of further requirements in order to improve current practice. Improvements were identified in respect of the replacement or refurbishment of equipment in the kitchen and kitchenette areas together with the general redecoration of the home. Arrangements need to be put in hand to avoid any repetition of the problems residents recently experienced in catering and cleaning following the temporary loss of their Chef and the knock on effect on other domestic staff. It was recommended that the record of activities provided for residents needs be improved to accurately reflect what activities have been offered to them and whether they have chosen to participate or not. The reasons for non participation should be monitored to determine whether this is purely a matter of choice or whether other choices might encourage participation from those residents The home provides a varied programme of training for staff but a significant number of the care staff had not received dementia training. As a large number of residents have dementia this topic should be mandatory and regular updates should be provided.This is a restated requirement. It was also recommended that all staff should receive updated training in Safeguarding Adults procedures annually. The Provider must undertake an annual quality audit to assess the Homes performance in relation to the National Minimum Standards and make the results known in writing to the Commission, residents, relatives and the other professionals involved in the home e.g. local authority staff and health professionals. A number of requirements/ recommendations were made in relation to staffing and management issues. These related in particular to the nursing unit and Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 8 identified the necessity to appoint a Deputy manager for the home who would also be the head of that unit Sufficient hours should be allowed for this dual role in order to fulfil both the nursing hours required and the management support hours. The recording of staffing rotas must be improved to clearly evidence the actual hours worked, by whom and on which shifts to clearly show any alterations made to the rotas. It is strongly recommended that the nursing unit be staffed by four health care assistants in addition to the nursing staff in view of the high dependency needs of residents. It is recommended that a deputy chef is recruited and the hours of the main chef are maintained within reasonable limits. Prior to the conclusion of the inspection the Provider had placed an advert for a deputy chef for the Home. It is recommended that the Provider reviews the history of successive managerial appointments to the home. It was recommended that priority attention is given to ensure that at least six formal sessions of supervision per year are provided for nursing and care staff in order to meet the Minimum Standard. 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.V365039.R01.S.doc Version 5.2 Page 9 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.V365039.R01.S.doc Version 5.2 Page 10 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&4 Quality in this outcome area is adequate. 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 residents’ care files and retained on the relevant unit. In respect of the nursing unit, neither residents with dementia, nor their representatives can be confident that their dementia needs will be adequately met, as this unit is not registered to provide dementia care. Neither have all the staff on this unit received adequate training in this area. EVIDENCE: Standard 3 We looked at four care plans, one on the nursing unit, one on the Dementia residential unit and two on the conventional residential care unit. All records included a copy of the pre-admission assessment. Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 11 Standard 4 On the nursing unit a number of residents presented with signs of dementia. Staff said that when residents on the dementia care residential unit required nursing care they were often transferred to the nursing unit. This unit is not staffed to meet the needs of residents with this condition and staff lack experience in this area. As the service is not registered to provide dementia care on the nursing unit the manager must ensure that the needs of all residents are met and staff skills are appropriate to meet those needs when the admission of residents is being considered, see Standard 30. See Restated Requirement 14 Standard 6 This Standard was not assessed, as the home does not provide an intermediate care service. Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 12 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 adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments were written for all residents, those seen did not always reflect total care needs and not all were up to date. Systems were in place to meet resident’s health care needs however recording and documentation needs to be improved and effective monitoring in place. Medicine administration was largely good although recommendations have been made to improve practice. Some concerns were noted in relation to resident privacy and dignity. EVIDENCE: Standard 7 The dependency assessment tool used by the Provider made it difficult for staff to evidence. On the nursing unit there were 21 residents, 13 required Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 13 assistance with feeding, 19 were doubly incontinent, many were suffering with dementia and confusion and 20 required 2 carers to provide personal care. One resident was assessed as category 1, which implied high dependency. The staffing levels on this unit were normally 1 senior nurse and 3 care assistants in the morning and afternoon, which we considered was inadequate. See Standard 27. See Requirement 11 The care records inspected for four residents included risk assessment, assessments of need and care plans to show how needs were to be met. Personal hygiene care plans included details regarding how the person liked to present themselves,including hair and nail care and showed resident choice was considered. Care plans were reviewed monthly and staff said that resident needs were reviewed with them and their families six monthly, and three monthly if the resident had a pressure sore. Due to recent concerns about the service both Bexley and Greenwich Social Services Departments care managers were in the process of reviewing the care and care records for all of their residents. We were advised that a fuller examination of care plans had been undertaken by them where deficiencies had been identified. Any further requirements or recommendations arising from those reviews should be addressed by the Home. The quality of the daily care and weekly progress reports could be more informative and support the implementation of care plans. See Recommendation 1 It is recommended that the dependency tool used should be reviewed to ensure that staff are enabled to accurately and easily assess the resident’s needs in order that adequate staffing levels are maintained. See Recommendation 2 ---------------------------------------------------------------------------------------------------Standard 8 The care records we case tracked included a risk assessment in relation to pressure sores, where appropriate. Equipment such as pressure relief mattresses and cushions were provided for residents where needed. Staff said that two residents on the nursing unit had pressure sores and both were admitted from hospital with these. As the local authority had reviewed these residents during the week of this inspection their records were not inspected. All residents were registered with a GP and there was evidence in the records seen that residents had been seen by a GP, chiropodist and other professionals when needed. Staff said that advice was obtained from a dietician and the tissue viability nurse when required to meet individual resident needs. Accident records were seen and showed that residents were monitored for up to 48 hours following an accident. Accident records varied as to the amount of Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 14 detail included and this area of assessment and recording should be improved. Monthly accident audits were completed and sent to head office. See Recommendation 3 Whilst formal complaints were not made, two relatives commented in returned LB Greenwich questionnaires suggesting that on occasion residents had unacceptable delays in being taken to the toilet and cleansing of dentures was sometimes overlooked. The management of the home need to be aware of these comments and address these matters accordingly As mentioned in the previous Standard both LB Bexley and LB Greenwich care managers had been involved in an extensive review of residents placed by them and shortfalls that were noted related to a lack of body mapping and questions relating to the accuracy of weight charts, care planning and evaluations, non dating and signing of entries in some instances. Specifically, these matters must be addressed by the home via training and supervision of care staff and management monitoring. See Requirement 1 Standard 9 Magement of medication was inspected on the nursing and dementia care residential units. Policies and procedures were provided and were last reviewed in 2006. Storage for medicine on both units was satisfactory and the temperature of the medicine fridge and the storage room was monitored. However, on the Dementia unit the medicine fridge thermometer needed a new battery and the fridge temperature was not recorded from 5/6/08. Satisfactory storage was provided for controlled drugs although neither unit had any of these drugs in stock, as they had not been prescribed for any residents at the time of inspection. Records were kept for receipt, administration and disposal of medicines. None of the residents were managing their own medicines. Medicine records and supplies were checked for two residents on both units and were found to be correct. In-house medicine audits were completed and copies of these showed that the service achieved over 90 compliance with medicine management in February, March and April 2008. Since the last inspection medicine profiles had been introduced for all residents. On the nursing unit a supply of homely remedy medicines were held, which had been agreed with the GP. However one medicine held in stock was not on the GP list and had been administered to residents. A second homely remedy medicine stock did not tally with the amount purchased and administered. Internal and external homely remedy medicines were stored together. On the dementia unit staff had added room numbers to boxed medicines and this was not considered safe practice. A recommendation made at the last inspection in relation to ‘as required’ medicines and an assessment of staff competency had not been addressed and has been repeated in this report. Room numbers must not be added to individually boxed medicines. Internal and external medicines must be stored separately. Residents must only be administered homely remedy medicines that are specifically agreed by the GP. Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 15 Accurate records must be kept for all medicines brought into the home including homely remedies. See Requirement 2 A protocol should be prepared for residents who lack capacity when they are prescribed ‘as required’ medicines. See Recommendation 4 Staff responsible for medicine administration and management should have their competency to do this assessed annually. See Restated Recommendation 5 Standard 10 Staff members were observed to be knocking on bedroom doors and asking their permission to enter bedrooms. Good interaction was seen between staff and residents and assistance was provided to residents when needed. Residents and relatives spoken with at the time of inspection did not raise concerns as to how staff respected their privacy and dignity. However, two relatives of residents commented in returned LB Greenwich questionnaires, that relative’s personal glasses were not being examined and cleaned, if required. This omission relates to both health and safety and respect of residents and I addition to those mentioned in Standard 8 must be addressed by staff. See Requirement 3 Overall, care plans that were seen covered issues related to resident dignity such as appearance, choosing what to wear, to encourage meal choices and opportunity to take part in activities. Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 16 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 adequate This judgement has been made using available evidence including a visit to this service. Activity records need improvement. EVIDENCE: Standard 12 The activity sheet in care records was not well maintained and must be improved to accurately record what activities have been offered to individuals and whether they have chosen to participate, or not. The reasons for non participation should be monitored to determine whether this is purely a matter of choice or whether other choices might encourage participation from those residents. See Recommendation 6 On two of the visits to the home residents were seen enjoying a bingo and music bingo session. The activity organiser had the help of volunteers for some sessions and residents were observed interacting well with the activity co-ordinator and the volunteers. Residents spoken with said they enjoyed the Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 17 activities provided for them. A social care plan was seen in one on the care records inspected and included the person’s interests. The activity co-ordinator said that care staff could be more involved with getting residents ready for and assisting with activities. However, in view of recent staff problems it was understood that this had not been possible. 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 Residents, relatives and staff members we saw were all concerned about the recent difficulties with meal provision. Domestic staff had been cooking meals recently and although they tried to maintain quality residents were unhappy and lots of food was returned uneaten. On the first day of the inspection a senior manager within Southern Cross assured us that as from the following day an agency cook would be on duty so that there would not be a repeat of the chaos in the provision of adequate meals. Also, despite an Immediate Requirement to provide an adequate liquidiser to prepare pureed food this item was not provided until over a week later, resulting in pureed food not being prepared adequately for residents. Lunch was observed on the nursing unit on the second day of the inspection 9th June. Tables were properly laid for the meal and the menu for the day displayed. On the nursing unit staff said that the pureed meals usually arrived first so staff could feed residents but as there was an agency cook on duty this did not happen. This meant that staff members were still feeding residents lunch at 14.15. The meal in the dining room was served and assistance given to residents as needed. During this meal there were more staff than usual to help with feeding as two new care staff were on induction, one staff nurse and four care staff were on duty and a relative who was a frequent visitor to the home also helped residents with lunch. Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 18 We acknowledge that this matter had been resolved by the time of the third day of inspection. See Requirement 4 Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Requirement and Recommendations were made to ensure that residents, relatives and others have confidence that all complaints will be taken seriously and acted upon. A Requirement was made to address failures in the significant events reporting/ notifications by the home. EVIDENCE: Standard 16 The complaints procedure was displayed and included adequate information about what people should do if they wanted to make a complaint. Information about the contact details for the Commission for Social Care inspection (CSCI) had been updated and there were timescales for staff to follow when investigating concerns. Guidance was provided about the different stages that people could follow if they were not satisfied with the response provided by the home. Generally,however, the documentation was not in order and we had to search for documentation to evidence that complaints had been dealt with appropriately. All documentation relating to complaints must be retained on the appropriate file that is readily available for inspection at any time. If there are any staff related disciplinary issues these may be separate but clearly identified as such within the complaints log. It was recommended that Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 20 complaints records should be filed sequentially i.e. complaint, acknowledgement, investigation, response and outcome i.e. whether substantiated or not and action taken to prevent a reoccurrence of the complaint. See Recommendation 5 Six complaints had been logged and had been dealt with in accordance with this Standard. However, we were aware that two other complaints had recently been made to the home that were not recorded in the log, these matters were shared with the Operations Manager who assured us they would be recorded and dealt with appropriately. See Requirement 5 Other matters that were referred to in questionnaires returned by relatives of residents suggested that verbal complaints or concerns expressed were not being recorded. It would be good practice for all staff members to be formally reminded that any complaints made should be recorded and that complaints represent a quality control tool that could assist the home to maintain or improve standards. See Recommendation 8 Standard 18 A policy and procedure was in place in relation to safeguarding adults. Staff spoken with had a good understanding of their role in safeguarding adults and understood the ‘whistle blowing’ policy. Three safeguarding adults referrals had only recently been made and were currently being investigated by the local LB Bexley Safeguarding Adults Team. As the outcomes were not known at the time of writing this report any matters of significance will be reported on in the next inspection report for the home. However, it was evident that in all three incidents Regulation 37 notifications had not been sent to CSCI or the placing authorities. This is a matter is of concern as the home has a legal responsibility to report all significant incidents/accidents within the home to the Commission. The Operations Manager acknowledged the shortfalls and undertook to produce new guidance and a tracking system to ensure this does not happen again. In respect of other incidents within the home since the previous it was noted that there had been a steady flow of Regulation 37 notifications that had been appropriately responded to by the home. See Requirement 6 The training matrix for staff members provided showed that in the past 12 months none of the staff team had received training on this topic and it is recommended that staff receive annually updated training in Safeguarding Adults. See Recommendation 9 Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 21 Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 22 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): 19,22 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents usually live in a safe and well - maintained environment, however this was compromised for a period of three weeks and action must be taken to prevent a reoccurrence. Residents have access to specialist equipment to maximise their independence but closer monitoring and replacement of worn items is required. Residents live in a clean and hygienic environment, however, this was compromised for a period of three weeks and action must be taken to prevent a reoccurrence. EVIDENCE: Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 23 Standards 19,22 & 26 On the first day of the inspection the person in charge of the residential unit had come in to clean carpets, as this had not been done due to the domestic staff having to workin the kitchen. A qualified Chef was not available at the time of the first day of inspection and the person doing the cooking was a nonqualified member of the domestic staff. See Standard 15. See Requirement 7 The dining room on the ground and second floors were in need of redecoration, the kitchenette areas needed replacement and the carpets were dirty and stained. Areas of the environment seen were not adequately clean. On the ground floor the carpets in bedrooms 10,12,15 and 16 were not clean. Two relatives seen were not happy with the current standard of hygiene in the home. On the first floor the dining room carpet was dirty and stained and needed cleaning and the carpets in bedrooms 32 and 47 required cleaning. Cleaning schedules generally had been severely disrupted owing to the staffing problems generated by the continued absence of a qualified Chef. We acknowledged that both the catering and domestic cleaning shortfalls had been improved by the time of the third day of inspection. However the facilities in the kitchen must be reviewed as the cooker hoods were mal functioning and inadequate freezer space was available. The dry storage area might better be utilised to house freezers and the dry foods stored where freezers currently are. The equipment provided should generally be reviewed such as frying equipment, blenders/ mixers to ensure they are working correctly. See Requirement 8 Standard 22 Staff reported problems with access to moving and handling equipment. Staff said they did not have slide sheets, appropriate hoist slings and some slings were worn or damaged. On the top floor the sling for one hoist was torn and on the ground floor one sling and one standing hoist was not operational as staff members did not have a suitable sling or belt. The sling for another hoist and the belt for a standing hoist on the nursing unit were also damaged and could not be used. This resulted in residents having to wait for assistance. It was noted on the third day of inspection that new slings had now been ordered and that six monthly service certification was due shortly from the servicing company. See Requirement 9 Standard 26 Staff had access to protective clothing, hand-washing facilities were provided and each floor had a sluice room. One of the washing machines that had been out of action for some time had been repaired by the third day of inspection, it was accepted that the home had experienced difficulty in getting it repaired. Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 24 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. Adequate staffing levels have not always been maintained and the staffing requirement must be reviewed on the nursing unit. Record keeping (staff rotas) must be improved. Training for staff in Dementia must be improved. Recruitment procedures were largely good but could be improved. EVIDENCE: Standard 27 Difficulties had arisen because of recent staff shortages particularly in relation to the ground floor nursing unit that did not have an established permanent staff team and recently suffered the resignation of the Deputy Home Manager and the head of that unit. The unit had suffered problems with lack of continuity of care. Prior to the inspection there was one shift when the nursing unit had only 1 Senior Nurse and 1 Care Assistant on duty. This meant many residents had to spend the day in bed and wait for care and meals. On another occasion three care assistants had been appropriately dismissed for refusing to Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 25 work. Whilst the minimum staffing requirement is one qualified Nurse and three care assistants on the nursing unit, or two nurses and three care assistants for am if there are more than 20 residents it is evident that the dependency needs are currently so high that it is strongly recommended that there should be an additional care assistant provided. This is further compounded by the number of residents with Dementia who are inappropriately placed as the unit is not registered for Dementia. Overall, the staffing ratio must be reviewed to assess whether the current staffing level is adequate to meet the needs of residents on this unit. See Recommendation 10 & Requirement 10 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. Regrettably, rotas that were provided to evidence whether staff members actually completed a shift were very difficult to read because of crossings out and alterations. There were inaccuracies established and the Operations manager acknowledged this and the need for a more systematic larger format and procedure for the accurate maintenance of rotas that clearly evidence those staff that have actually worked a shift. The Operations manager undertook to develop a new system that would be better managed and accountable. Some members of staff had also worked very long shifts or too many hours within a week. By the third day of the inspection this practice had ceased and the Operations manager stated that this situation would not occur again. See Requirement 11 Prior to the recent illness of the Chef it was noted that he had been regularly working every day of the week, this anmounted to an excessive number ogf hours, the Operations Manager stated that this would now cease and that an advert for a deputy Chef had already been placed in order to address this. See Recommendation11 Standard 28 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 employee files were inspected. Files were well organised and mainly complied with regulation. However the following omissions were noted; two files did not have a recent photograph of the person, one file had two character references for the person and neither had been verified as genuine and for one person there had not been a check made with the Nursing & Midwifery Council Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 26 (NMC) as to their registration. During the course of the inspection administration staff did confirm with the NMC that the person was currently registered although this should have been done prior to them starting work. See Requirement 12 Standard 30 Care staff spoken with said they had access to training needed to do their work. On the employee recruitment files seen there was evidence of training such as first aid, moving and handling, food hygiene, care planning and NVQ training. A staff training matrix was provided and showed that 21 staff had attended a 2 hour training session on dementia care, provided by an in house Registered Nurse, this is not adequate and should be provided by trained personnel who specialise in the care of dementia. In view of the number of residents on the first and ground floor who suffered with dementia the level and amount of training was not considered tobe adequate. The matrix showed that in the previous 12 months all staff had access to training such as fire safety, M&H, food hygiene and medication management and update training. See Requirement 13 The training matrix for staff members provided showed that in the past 12 months none of the staff team had received training on Safeguarding Adults and it is recommended that staff receive annually updated training in this area. See Recommendation 9 Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 27 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has lacked consistent management support owing to a succession of different managers over a period of three years. Some quality assurance systems were in place however a report had not been sent to the Commission. A financially accountable system was in place to safeguard residents’ finances. Whilst health and safety matters were attended to, better monitoring is required in respect of slings and belts for hoists and the issuing of Regulation 37 notifications regarding significant incidents to the Commission and placing authorities. EVIDENCE: Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 28 Standard 31 Currently the home has no permanent manager and has been without a Registered Manager for three years following a succession of nine managers and acting managers. It is understood that the permanent managers had either resigned or been dismissed, prior to any application being made to apply to become the Registered Manager for the Home with the Commission. This has resulted in ongoing instability for both residents and staff members alike and it is very important that this continued disruption and lack of continuity be brought to an end. Urgent attention is required by the Providers senior management to address the reasons for the recent chain of events regarding senior staff leaving and also the apparent lack of morale amongst many of the remaining staff members. The home has also suffered from a recent period of absence by the Chef due to illness. We were advised by a representative of the Providers senior management that a replacement chef would be organised the following day, and a senior manager would take on management of the home within two days, this did not occur, as we were assured. The Operations Manager who is currently in charge of the home has stated that a new manager has been appointed and will commence duties by mid July 2008. The Operations manager agreed with us that a period of induction/ transition should be afforded the new manager, by the Operations Manager herself, and we were also told that the new manager would be involved in the appointment of a new Deputy Manager as soon as there was a suitable candidate available. The Operations Manager also stated that the deputy post would be offered on the basis that a suitable number of hours over and above the nursing hours required would be allowed for the performance of management duties in the absence of the Home Manager. See Recommendation 12 Standard 33 There was evidence that the Operations Manager and the Homes manager completed audits on the quality of the service. The audits were based on the national minimum standards and covered areas such as medicine management, complaints, the environment, pressure sore care and prevention, activities and health & safety. The audit for May 2007 showed an overall achievement of 75 , which had not been considered adequate. Visits were made to the home under Regulation 26 and reports were seen for February, March and April 2008. Resident meetings were held and minutes were seen for the meeting on 16/4/08. 15 residents attended and the minutes showed Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 29 residents could have their say about issues that mattered to them such as the meals provided. Relative meetings were also held and minutes were seen for the meeting on 23/9/07. This did not show how many people attended but did show that previous minutes were discussed. Topics discussed at this meeting included the management of laundry, dementia care and end of life care. Meetings were held with unit staff, heads of departments and specifically for health & safety. The Operations Manager had completed an annual report of the service for the Providers and this was included in a report for the whole organisation. However, to comply fully with this standard a copy of the service review together with any remedial action plan must be made available to the Commission, residents and others. It was noted that the Operations Manager had organised a relatives meeting the evening before the third day of inspection as she had felt this to be particularly necessary in view of the recent disruption within the home and the need to inform them of the imminent plan to appoint a full time permanent manager. See Requirement 14. Standard 35 There had been some changes to the way resident’s personal allowances are managed. The home no longer held residents’ money but had a float of cash to use. This money was used to pay for hairdressing, chiropody and other personal items residents required. Receipts were obtained for money spent and the amount charged to the individual resident’s account. Resident’s personal allowance was held in a non-interest bearing account for ‘residents of Marlborough Court. Money received for residents was paid into this account and receipts provided. Individual records were held on the computer and made available to residents and relatives on request. The manager and administrator managed the bank account and signed cheques. Personal allowance records were checked for two residents and balances were found to be correct with a clear audit trail of the whole process. The Manager and Administrator ensure all residents have access to personal allowances and where needed contact relatives to obtain this money. Standard 36 Staff spoken with said they did receive supervision however they added that this had not been provided very regularly recently. Supervision files were viewed for 8 employees. Four people had one supervision session in 2007 and four had 4 sessions but there was no evidence to show that supervision had been provided since October 2007. Regular supervision of staff is essential in order to ascertain that staff needs in terms of development and training can be identified and properly provided for. It is highly recommended that priority attention is given to provide at least six formal sessions per year for each staff member in order to meet the minimum Standard. See Recommendation 13 Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 30 Standard 38 With three exceptions, safety records that were seen showed attention was given to providing a safe environment for residents and others. Records seen were up to date and showed that service checks had been carried out when due, eg certificates of inspection of the two lifts, gas and electrical certificates and fire alarm testing. Records seen included those for servicing for hoists and assisted baths, however, as stated in Standard 22 on the top floor the sling for one hoist was torn and on the ground floor one sling and one standing hoist could not be used as they did not have a suitable sling or belt. The sling for another hoist and the belt for a standing hoist on the nursing unit were also damaged and could not be used. This resulted in residents having to wait for assistance. See Requirement 9 The maintenance technician completed in-house safety checks on items such as bed rails, wheelchairs, hot water temperatures and window restrictors. Fire safety arrangements were good. Regular checks were undertaken to ensure that the fire alarm system, emergency lights, fire extinguishers and fire doors were in working order. Staff received fire safety training and attended fire drills. As stated in Standard 8 Accident records were seen and showed that residents were monitored for up to 48 hours following and accident. Accident records varied as to how well the details were recorded and this area could be improved. See Recommendation 3 Monthly accident audits were completed and sent to head office. The records showed that when residents received medical attention following accidents, on occasion there were shortfalls in documentation and assessment. This was highlighted during an annual review carried out recently by a LB Lewisham care manager See Recommendation 3 Other recent incidents indicate that Standard 18 was not complied with, in that the appropriate notifications were not sent to the Commission or placing authority as required under Regulation 37. See Requirement 7 Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X 2 X X X 2 STAFFING Standard No Score 27 1 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 2 X 2 Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 32 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 OP8 Regulation 12 &13 Requirement Within care planning and evaluation the recording of body mapping, weight charts nutritional requirements wound management and the routine dating and signing of entries must all be improved. Records must be regularly evaluated and monitored by senior staff. Room numbers must not be added to individually boxed medicines. Internal and external medicines must be stored separately. Residents must only be administered homely remedy medicines that are specifically agreed by the GP. Accurate records must be kept for all medicines brought into the home including homely remedies. Residents glasses must be inspected & cleaned as necessary, dentures cleaned routinely and assistance to go to the toilet provided promptly. At all times residents must be provided with adequate nutritious wholesome food. DS0000006766.V365039.R01.S.doc Timescale for action 01/09/08 2. OP9 23 & 13 01/09/08 3 OP10 4 & 12 01/08/08 4 OP15 16(i) 01/09/08 Marlborough Court Care Centre Version 5.2 Page 33 5. OP29 19 Suitable back up arrangements from qualified personnel must be provided in the absence of the main chef. The Registered Person must ensure that all information required within the recruitment process in accordance with this regulation is obtained. 01/09/08 6 7. OP16 OP18 4 Schedule 1 37 8. OP38 13 All complaints written or verbal 01/08/08 must be entered in the complaints log promptly. Regulation 37 notifications in 01/09/09 relation to significant events such as serious accidents or Safeguarding Adults issues must be sent to CSCI and notified to placing authorities without delay. The home must ensure that it 01/08/08 maintains a good standard of hygiene, keeping carpets clean, and redecoration. 9 OP38 13 10 OP22 23 Repairs or refits the kitchenettes on the units. Cooker hoods and other equipment in the kitchen must be replaced or refurbished. Also storage reviewed as freezer capacity is low and the dry storage area needs review. Staff must provide adequate equipment to M&H residents and ensure it is safe to use. And ensure there is a system for promptly ordering replacement slings and belts 01/10/08 01/08/08 11 OP27 18 The nursing unit must be staffed, 01/10/08 at least, in accordance with the staffing notice issued by the former registration authority: 2 nurses and three care assistants am when over 20 resident accommodated 1 nurse DS0000006766.V365039.R01.S.doc Version 5.2 Page 34 Marlborough Court Care Centre 11 OP27 Schedule 4 & 17 12 OP29 19 and three care assistants when 20 or less accommodated. In view of the high level of dependency of residents and many with Dementia the home must as a priority review staffing numbers in respect of residents’ needs and provide the results of the assessment in writing to CSCI. Staffing rotas must be retained securely in the home and they must accurately reflect what shifts had actually been worked by individual staff members. The Registered Person must ensure that all information required within the recruitment process in accordance with this regulation is obtained. Restated Requirement, the previous date of 0109/07 was not complied with. The Registered Person must 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 08/09 must be submitted, in writing to CSCI. Restated Requirement, the previous date of 01/10/07 was not complied with. The Registered Person must ensure a report is written for quality reviews undertaken and supported by an improvement plan to address issues identified. This report must be made available to residents, relatives and others and a copy sent to CSCI and made available to residents and relatives and other professionals involved. 01/08/08 01/09/08 13 OP30 19 (5) g 01/09/08 14 OP33 24 01/10/08 Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 35 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard OP7 Good Practice Recommendations 1. The quality of the care plans daily care and weekly progress reports could be more informative and support the implementation of care plans. The dependency tool used should be reviewed to ensure it provided an accurate assessment of the resident’s needs so that adequate staffing levels were maintained. Accident records varied as to the details included and this area of assessment and recording should be improved by providing more detail. A protocol should be prepared for residents who lack capacity when they are prescribed ‘as required’ medicines. Staff responsible for medicine administration and management should have their competency to do this assessed annually. Restated recommendation The activity sheet in care records was not well maintained and must be improved to accurately record what activities have been offered to individuals and whether they have chosen to participate, or not. The reasons for non participation should be monitored to determine whether this is purely a matter of choice or whether other choices might encourage participation from those residents The complaints records should be filed sequentially i.e. complaint, acknowledgement, investigation, response and outcome i.e. whether substantiated or not and action taken to prevent a reoccurrence of the complaint. It would be good practice for all staff members to be formally reminded that any complaints made should be recorded and that complaints represent a quality control tool that could assist the home to maintain or improve standards. DS0000006766.V365039.R01.S.doc Version 5.2 Page 36 2. OP7 3. OP8 4. 5. OP9 OP9 6 OP12 7 OP16 8 OP16 Marlborough Court Care Centre 9 10 11 12 OP18 OP27 OP27 OP31 It is recommended that staff receive annually updated training in Safeguarding Adults. It is highly recommended that the nursing unit is staffed by four care assistants in addition to nursing staff in view of the high dependency needs of residents. It is highly recommended that a deputy chef is recruited and the hours of the main chef are maintained within reasonable limits. It is recommended that Southern Cross management review the history of successive managerial appointments to the home and the reasons behind the apparent low morale amongst some existing staff. It is highly recommended that priority attention is given to provide at least six formal sessions per year for each staff member in order to meet the minimum Standard. 13 OP36 Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Marlborough Court Care Centre DS0000006766.V365039.R01.S.doc Version 5.2 Page 38 - 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. 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