Inspection on 08/06/06 for Marlborough Court Care Centre

This inspection was carried out on 8th June 2006.

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

The inspector 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 12/07/07

Marlborough Court Care Centre 22/12/06

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 Key Unannounced Inspection 8th June 2006 09:10 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.V293773.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 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 Ashbourne Limited and Exceler Health Care Services Leasing Limited Mrs Patricia Holttum Care Home 77 Category(ies) of Dementia (27), Old age, not falling within any registration, with number other category (50) of places Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 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 27 beds for elderly people with dementia Date of last inspection 8th November 2005 Brief Description of the Service: Marlborough Court Care Centre is a purpose built, three-storey home situated in North Thamesmead overlooking the River Thames. The home consists of 21 single bedrooms on the ground floor for people requiring nursing care, 27 single bedrooms for older people with dementia on the first floor and 29 single bedrooms for older people requiring personal care on the second floor. All of the rooms have en-suite facilities. Each unit has a separate dining room, two lounges, toilets and three bathrooms. Separate laundry, kitchen and staff changing facilities are provided on site. Outdoor areas include a garden, patio area and an aviary at the front of the property. Visitors can park in the private car park in front of the home. Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over one day on 08/06/06 by two Inspectors and lasted for 9.00 hours. The Inspectors examined care and health and safety records and staffing records. The inspectors interviewed eight residents, four relatives and eleven members of staff. All residents and relatives interviewed were happy with the level of service except one resident on the ground floor who felt the only person who spent time talking to him was the trained nurse, a visitor interviewed on the ground floor unit also commented that care staff did not spend time talking to residents. The recent provision of a new manager appears to having a positive impact on both residents and staff members. What the service does well: What has improved since the last inspection? The home has appointed a new manager who has been well received by both residents and staff members. An additional member of the domestic team has been appointed and the maintenance man has been appointed as a permanent member of staff and has made a significant contribution to ensuring that health and safety matters are attended to in accordance with Regulations and maintenance matters attended to promptly. Overall, the staff morale appeared to be much improved and the manager has instituted early morning meetings with all heads of units and other heads to Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 6 identify any problem areas and staff reported to the Inspectors that this system worked well and facilitated good communication within the management team. What they could do better: The Home must produce an up to date Statement of Purpose and Service User Guide and send both documents to the CSCI and supply each of the residents of the Service User Guide. Records to do with the health, welfare and social care needs of residents need some improvement in order to more accurately reflect any identified needs and care plans must be developed to clarify how these needs will be met. Care plans relating to wound care must provide clear information for staff about the current treatment regime. A number of areas to do with how medicines are managed must be improved and a requirement has been made in respect of these detailed in the Health and Personal Care Section of the report. Staff members must ensure that residents who need assistance with eating are identified and that they are given appropriate assistance at mealtimes. Overall, the home was clean but a few areas were neglected and require greater input. The manager must ensure that adequate staff members are provided to meet residents’ needs, particularly on the ground floor unit and ensure that the staffing notice for the service is complied with. Nursing staff should ensure that one assessment tool is used to assess resident’s risk of developing pressure sores. As residents referred to Bexley PCT for allocation of a pressure relief mattress are assessed using Waterlow, consideration should be given to using this tool. A number of areas were identified as needing refurbishment or redecoration and they are identified in the Environment section of the report. Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 7 The manager should ensure that environmental changes are made on the first floor unit in order to support the needs of people with dementia and that all residents are enabled to select the food they would prefer from the menu. The provision of specialist training could further develop the skills of the activities workers. 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. Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 & 5 (Standard 6 does not apply to this home.) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In view of the change of management the home will need to submit a new Statement of Purpose and Service Users Guide. A senior member of staff undertakes a formal assessment of residents needs prior to admission. The assessment included assessing residents health and welfare needs and judging whether there were any particular safety issues such as a history of falls. The home confirms the arrangements for admission in writing and provides information about the care and facilities provided prior to admission. EVIDENCE: Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 10 The home has been taken over by Southern Cross since the previous inspection and therefore the Statement of Purpose and Service user Guide will need to be amended. The manager has also changed and will be applying to the CSCI to become the registered manager. The Manager agreed to forward copies of the new documents to CSCI as soon as they are produced. It was also noted that copies of the Service User Guide for residents on the first floor unit were kept in the filing cabinet in the office. One of the residents on the ground floor said he had never received a Service User Guide and copies were not seen in the rooms visited on this floor. One of the complaints received by the home involved a resident who had not received a Service User Guide and a relative who was unaware who to complain to, a situation that might have been averted had the resident received a copy. A copy of the Service User Guide must be given to each service user including any on respite care, individually, for their retention and must include up to date information that is continually updated as necessary. See Requirements 1 & 2. Four, service user care files were examined that showed that a senior member of staff undertakes a formal assessment of residents needs prior to admission. The assessment included assessing residents health and welfare needs and judging whether there were any particular safety issues such as a history of falls. The home confirms the arrangements for admission in writing and provides information about the care and facilities provided prior to admission. Standard 5 was not assessed, as this home does not provide an Intermediate care service. Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some of the care plans examined did not adequately reflect how residents’ assessed needs would be met. The management of medication needs to be improved in some areas. Staff members maintained residents’ dignity and privacy. EVIDENCE: Two sets of records were assessed on the ground and first floor units and four on the second floor. On the ground floor and second floor unit records were mostly satisfactory although some parts of assessments were incomplete and wound care documentation was poor on the ground floor. Care plans and assessments were reviewed regularly but input from relatives was not always obtained. Some residents were assessed of the risk of developing pressure sores using two different tools. For example one resident was assessed using Waterlow and Braden and was identified to be both at low and high risk of developing sores. See Recommendation 1 Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 12 One resident had developed two pressure sores in the home. Advice had been sought from the Tissue Viability Nurse and the care plan indicated how one of the sores should be managed. It was not clear from the records how the other sore should be dressed. The records indicted that the wounds had been treated with a variety of different dressings and creams during the previous month. See Requirement 3. There was written evidence that some of the more frail residents were repositioned regularly. Documentation on the first floor unit was mostly good although some gaps were noted on assessment records. Records of accidents had improved. The inspector was told that one resident with facial bruising had sustained the injury during a fall. A record of the accident was maintained in the residents care notes and on an accident form and staff had provided first aid treatment. The accident form stated that the form should be passed to the manager for follow up. This did not appear to be happening. Relatives were more involved with care planning on the first floor unit. The management of medication was assessed on the ground and first floor units. The arrangements for storing medication on the ground floor unit was good but on the first floor unit the temperature in the medication room was too high. Records of receipt of medication were good for medication received from the pharmacist but medication received from other sources such as hospital, were not always recorded. Residents were receiving their prescribed medication regularly but some discrepancies were noted where medication from the previous month was used. Staff must ensure that records enable staff to carry out a full audit trail. One resident on the ground floor unit was receiving one medicine twice a day but the label on the container stated the medication should be administered once a day. No records of disposal of medication were maintained on the ground floor unit as the contractor had advised staff that this was not necessary. The nurse in charge was advised that care homes are required to maintain up to date records of medicines sent for disposal under The Care Homes Regulations. See Requirement 4. On the ground floor unit the morning medication round was not completed until 11am. This reduced the gap between the breakfast and lunchtime doses of some medicines. See Standard 27 re staffing. Access to community health and social care services were good. The records seen indicated that residents had been assessed or reviewed, for example, by the GP, District Nurses, Optician and Care Managers. Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 13 Residents interviewed said that staff members treated them with respect. Staff members who were observed by the Inspectors were interacting with residents in a professional and caring manner. Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs two part time activity staff who are responsible for facilitating a regular programme of activities and entertainment for residents. Both of the activity staff had attended dementia training but had identified to previous managers the need for more specific training relating to their role. See Recommendation 2. Since the last inspection the reminiscence room had been converted into a dedicated activities room. Most of the activities took place in this area but some sessions took place on the units. Monthly entertainment was arranged and some outings had taken place during the Christmas period and summer months. Some residents had been supported to visit a local community centre for coffee or walk along the river path. Room visits were undertaken for residents that were bed bound or too frail to attend group sessions. Staff provided a weekly shop for residents to purchase toiletries and sweets. Individual records of activities were maintained for each resident. The Inspector again recommends that consideration is given to providing the home with greater access to transport facilities for residents. Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 15 See Recommendation 3. The dining room on ground floor and second floor units were nicely laid in preparation for lunch. Condiments, napkins, juice, a copy of the menu and fresh flowers were provided on each table. Residents on the ground floor unit said the food was “ok” and there was always plenty to eat. Some concerns were expressed about not being able to select their choice of food from the menu “there is no choice, you lump it, there is nothing else” and some residents said that lots of the dishes on the menu included minced meat. See Recommendation 4. Some of the more dependent residents on the ground floor nursing unit were not given appropriate support and assistance during the lunch period. One resident who appeared very frail and was in bed had a full plate of food sitting on his chest, another resident was not suitably positioned to eat her meal and one resident had a pureed meal covered in cling film placed on her table but was not assisted to eat. See Requirement 5 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. Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An updated Service User Guide must be produced and a copy given to each resident this will further facilitate awareness of the complaints procedure. Prompt action is taken to investigate adult protection concerns and appropriate measures adopted in accordance with local Adult Protection Procedures. EVIDENCE: The home has a policy and procedure for complaints management and is displayed in the entrance area to the home. Records were maintained in relation to complaints and the outcomes of the subsequent investigations. Only one complaint had been received by the home since the previous inspection in November 2005. This was a minor complaint, was substantiated, and had been dealt with both appropriately and to the satisfaction of the complainant. In response to the previous requirement regarding the recording of complaints a new log had been created and the manager had adopted the format suggested by the Inspector for recording and dealing with complaints. The home does not, however, currently provide an up to date Service User Guide that is made available to every resident. See Requirement 2. The manager is aware of this shortfall and stated that one will be given to every resident when the updated version currently being prepared is available. Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 17 The Service User Guide is required to contain the details of the system for dealing with complaints in the home and also state the contact details of the CSCI to facilitate residents wishing to complain to the CSCI. A second complaint was made, not directly to the home, but to a care manager within Bexley social Services Department and the allegations were investigated jointly by officers from Bexley Social Services and the then acting manager of Marlborough Court. The matters investigated were an allegation of verbal abuse toward a resident by a member of care staff and neglect regarding general care of this resident. A second issue related to the failure by a senior member of staff to report the allegations to the manager of the home. The first allegation was substantiated and the second could not be determined. This allegation was also notified to CSCI by the home as required under Regulation 37 when the initial complaint was made. The Inspector is satisfied that this matter was dealt with and appropriate measures were taken in relation to two members of staff involved and in accordance with Adult Protection procedures and that there is a system to ensure adequate protection of residents within the home. The care staff member no longer works at the home and a referral made to the POVA list at the Department of Health. Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ongoing maintenance and health and safety issues have featured heavily in all but the previous inspection these matters continue to show improvement and the system for reviewing and monitoring these areas is now well organised. The maintenance log for the home was well maintained and has been improved to demonstrate that items are reported, checked and dated. The home has now appointed a fulltime permanent maintenance/ handyman and a third domestic staff member under the supervision of the housekeeper. Each of the floors has a dining room and at least two lounges. The rooms are used for different purposes such as social events and entertainment and relaxation. All of the floors had at least one lounge with a television and music system and other quieter areas where service users could meet visitors or socialise. On the day of inspection the weather was good and many service Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 19 users from each of the units were relaxing in the garden area to the rear of the home where sun shades and pergolas had been put up along with ample seating and small tables. There were a variety of baths showers and toilets on each floor that met Standard 21. A variety of equipment was provided and being used by staff and service users in the home. A call bell system is fitted in all of the service users rooms, en suite and communal areas and it was noted on two occasions that when activated the calls were answered promptly by staff members. On the second floor unit it was noted that call bell leads were appropriately connected and safely placed. The passenger lifts provide access to all floors. Some of the service users were using pressure relieving mattresses and cushions. It was noted that following a restated requirement made at the previous inspection, a review of hoisting equipment had been conducted and new hoists and slings provided where necessary. It was also noted that the maintenance man had conducted an inspection of bed rails and that he had recorded a fault with All of the bedrooms are single occupancy with en-suite facilities. The private space provided for service users has not changed and those viewed on the day of inspection met Standard 24. On the day of inspection most parts of the home were clean, tidy and odour free but attention to detail was poor in some areas. In the ground floor dining room there was dried food particles on the wall and under the serving hatch there was a collection of dust and dirt. There was a collection of hair in some of the plugholes and some of the baths were dirty. In one bathroom on the ground floor used towels were left on top of the toilet cistern and used gloves were placed in an open top bin. There was a pool of water on the floor near the shower. See Requirement 6. Hand washing facilities were provided for staff and residents. No significant maintenance issues were noted but the paintwork on the boxing over the pipe work in the bathrooms and toilets on both floors was chipped and worn. The flooring in the ground floor shower room was marked and the wall in room 12 was damaged. The shower attachment in bathroom two was broken and the worktop behind the taps in the ground floor dining room was damp and loose. See Recommendation 5. Radiators and covers were examined and were fixed securely to the wall. The first floor unit did not provide many visual aids to assist people with dementia to locate their rooms and commonly used areas such as the toilets and lounges. Some photographs of residents were placed outside their rooms but these were often positioned too high or had been pulled down, as they were Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 20 not fixed securely. En suite areas and toilets were difficult to identify, as the doors all looked the same. See Recommendation 6. A new carpet had been fitted in the corridor on the ground floor unit and plans were in place to fit a new carpet in the corridor on the first floor unit. On the nursing unit equipment to assist and promote residents wellbeing and comfort was provided. This included pressure relief mattresses and cushions, raised toilet seats, grab rails and standing aids. Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 appointment of a new manager and the acquisition of the home by Southern Cross had resulted in changes in the style of management that had evidently brought about improvements in staff morale. Recruitment procedures are well handled, and there is a good induction process in place. The Company have training courses available for mandatory subjects, but not all staff had completed these. Further training should be provided in dementia care. EVIDENCE: The staffing level on the first and second floor units was satisfactory. On the ground floor nursing unit there was one trained nurse and three care staff on duty. Discussions with staff and examination of duty rosters suggested that the home had not been complying with the minimum staffing notice for sometime. In addition to the unit not having adequate trained staff one of the carers was undertaking her first shift in the home. The carer had attended a Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 22 one-day induction training session in another Southern Cross home and did have some experience of care work. The unit was full and busy. The breakfast medication round did not finish until 11am as the staff nurse was busy trying to obtain an urgent blood sample and dealing with other issues. Some residents were not adequately supervised or assisted to eat during the lunch period and the new carer was working largely unsupervised with some very dependent residents. Some residents on the ground floor unit told the inspector that staff did not talk to them, as they were always busy. One resident said the trained nurse on duty was the only person who spent anytime talking to him. The resident said he “would love to have someone to talk to”. One visitor told the inspector that care staff did not spend time talking with residents and often carried out difficult moving and handling tasks requiring two staff, independently. It was not clear whether this was due to staffing difficulties or poor teamwork. See Requirement 7. Domestic staff members were observed to be working hard to keep the home clean. The Housekeeper confirmed that she is now assisted by 3 other domestic staff and between them clean all 3 floors every day. The home had therefore recruited a third person as suggested at the previous inspection. The home had appointed a new maintenance person, however the Inspector was concerned to note that he was splitting some of his shifts between a neighbouring home. Both the manager and area manager confirmed that this was a temporary measure and that his full hours would be retained for Marlborough Court and resumed in the near future. One of the Inspectors examined staff files, including 1 for a newly recruited member of staff. The files were well maintained, and included POVA First checks for staff, and evidence of CRB checks; 2 written references; detailed application form and health questionnaire; copies of documentation to confirm identity, and copies of qualification certificates. All staff files included a recent photograph in accordance with the amended Schedule 2 in the Regulations. Copies of work permits had been obtained where applicable, and nurses’ PIN numbers had been checked. The Inspector noted that files included job descriptions, and confirmation of successful job application. Staff members’ training records are retained in their files, and there is a training matrix held on the computer. This showed that training for mandatory subjects was booked, and for some subjects, (e.g. fire awareness), most staff had received recent training. For other mandatory subjects, there were numbers of staff still waiting for training, or for updates. Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 23 A completed induction programme was viewed in one file, and this showed a detailed and comprehensive induction process is provided for new staff members. Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31- 33 & 35- 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new manager had already made a positive impact on the running of the home and had been well received by both residents and staff members. The home is run in the best interests of service users providing regular meetings with service users and advocates/ relatives. The survey of residents’ views was on display in the entrance area to the home. Service user’ rights, including financial, are safeguarded by the homes record keeping and policies and procedures, however the shortfalls noted in relation to care planning and medication documentation need to be addressed. The health safety and welfare of service users are promoted and protected. EVIDENCE: Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 25 The home now has a newly recruited manager and the Inspectors were informed that this person would be applying to be come the registered manager in the near future subject to a satisfactory probationary period. This must not be delayed as the home has been without a registered manager for over a year and had three temporary managers following the departure of the previous registered manager. See Requirement 8. It was evident from interviews with both residents and staff members that the new manager has already made a positive impact on the home. Staff morale was noticeably better and both residents and staff members expressed that overall, the management of the home was improved. One visitor told the Inspector that the new manager had already made some improvements in the home. The visitor said the new manager was taking a firmer line with staff that did not perform well and expected a high standard of care. Staff said the new manager was “firm but fair” and was dealing with staff issues promptly. Residents said they had met the new manager during her visits to the units. All of the residents and relatives spoken with said they would be happy to approach the manager if they had concerns. The system for dealing with residents’ personal finance was examined and a good audit trail was seen and no errors found in respect of the three cases that were individually examined. Receipts are obtained for service user expenditure and an ongoing ledger records all money credited and debited in respect of individual service users. The person responsible within the home is the administrator who ensures records are retained in lockable cabinets and she is the sole key holder for the lockable safe where all money is retained. Additionally, the system is subject to spot checks at any time by the person who conducts the monthly Regulation 26 visits to the home and an annual external audit. A previous requirement to ensure that a survey of residents’ views on the running of the home and the service provided had been conducted and is placed in the reception area for all visitors to see. A multidisciplinary meeting is held monthly when visiting professionals can express their views on the running of the home and minutes retained of these meetings. It was evident that efforts were being made to reinstate regular meetings with residents and relatives. Regular, monthly visits had been conducted by the responsible person, as is required, under (Regulation 26) and the reports made available to the CSCI as required. The level of formal supervision sessions for care staff remains below the Standard but evidence was available that this was improving with sessions Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 26 scheduled and the manager had clearly discussed the need for improvement with her supervisory staff, the Inspector has not therefore made this a requirement on this occasion. 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 the Inspector was pleased to note that the maintenance man had been permanently appointed to his position 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. As noted in Standards 7 & 9 some shortfalls were noted in relation to care plans and medication record keeping. See Requirements 3 & 4. Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 3 2 3 Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 28 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 OP1 Regulation 4 Requirement Timescale for action 01/09/06 2. OP1 4 3. OP7 14 & 15 4 OP8 14 & 15 The Registered Person must provide a Statement of Purpose available for reference in the home and submit a copy to the CSCI. The Registered Person must 01/09/06 ensure that a Service User Guide is provided for every service user, individually, including any short-term admissions. A copy must be submitted to the CSCI. The Registered Person must 01/09/06 ensure that residents health, welfare and social care needs are assessed and that care plans are developed to meet identified needs. Care plans relating to wound care must provide clear information for staff about the current treatment regime. The Registered Person must 01/09/06 ensure that residents health, welfare and social care needs are assessed and that care plans are developed to meet identified needs. Care plans relating to wound care must provide clear information for staff about the current treatment regime. DS0000006766.V293773.R01.S.doc Version 5.1 Marlborough Court Care Centre Page 29 4 OP9 13 (2) 5 OP15 12 (4) 6 7 OP26 OP27 23 (d) 18 (1) 8. OP31 8 The Registered Person must ensure that: Accurate records are maintained for all medicines received in the home That the temperature in the first floor medicines room is maintained at 24 degrees centigrade or below. Accurate records are maintained for all medicines disposed of by the home Staff members check that the information on the medication chart corresponds with the instructions on the medication label. Staff members maintain a record of medication carried forward from the previous month. The Registered Person must ensure that residents are given appropriate assistance at mealtimes. The Registered Person must ensure that all parts of the home are kept clean. The Registered Person must ensure that adequate staff numbers are provided to meet residents needs. There must be no regression on the staffing notice. An application by the manager to become the Registered Manager must be submitted to the CSCI as soon as possible. 01/09/06 01/09/06 01/09/06 01/09/06 01/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 30 No. 1. Refer to Standard OP8 Good Practice Recommendations The Registered Person should ensure that one assessment tool is used to assess resident’s risk of developing pressure sores. As residents referred to Bexley PCT for allocation of a pressure relief mattress are assessed using Waterlow, consideration should be given to using this tool. The Registered Person should provide specialist training for activity staff. Consideration should be given to providing a mini bus for the home to further facilitate outings for residents in smaller numbers. Restated Recommendation. The Registered Person should ensure that residents are given the opportunity to select the food they prefer from the menu The Registered Person should: • Repaint the boxing over the pipe work in the bathrooms and toilets • Clean or replace the flooring in the ground floor shower room • Repair the damaged wall in room 12 • Repair the shower attachment in bathroom two • Replace the worktop in the ground floor dining room. The Registered Person should ensure that environmental changes are made on the first floor unit to support the needs of people with dementia. 2 OP12 3 OP12 4 OP14 5 OP19 6 OP22 Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Marlborough Court Care Centre DS0000006766.V293773.R01.S.doc Version 5.1 Page 32 - 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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