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Inspection on 08/11/05 for Marlborough Court Care Centre

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

This inspection was carried out on 8th November 2005.

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

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

What the care home does well

The Company has responded well to requirements and recommendations, and shown a concern to provide good care. Staff members were welcoming and friendly, and one of the Service Users said that "the staff are very kind and look after me well." The Inspectors thought the range of activities were good

What has improved since the last inspection?

What the care home could do better:

The Inspectors noted that although general health care was good, and preadmission assessments were reliably carried out, some of the Service Users had deteriorated since their admission, and were possibly out of category. There is a requirement to ensure that Service Users with increasingly high dependency needs are re-assessed, and placements are looked for in other units if necessary. If Service Users are not correctly placed, this has an effect on the adequacy of staffing numbers, and availability of equipment. Staffing levels must accordingly, be regularly reviewed to ensue the health and welfare of service users. Hoists were serviced on the day of the inspection. One of these failed the tests, and needs to be repaired or replaced. The Inspectors were also concerned that existing hoisting facilities may be inadequate, as staff had to wait for hoists to be transferred between floors at some times. There is therefore a requirement to review hoisting facilities generally, and provide these in line with the assessed needs of the residents on each floor. Medication procedures were generally satisfactory, but there were 3 items of concern. These have been identified in a requirement.The home must have a complaints log that clearly records progress, response and outcomes to complaints made to the home. Staff files were examined, and there was a good system in place. However, some new staff members did not have a recent photograph in place, and there is a recommendation to ensure that these are included. Mandatory staff training had been booked for all relevant subjects. The staff training matrix showed that some staff had not yet completed all required training, and there is a recommendation to ensure that all staff complete the required mandatory subjects and also that ongoing training is provided in dementia care. The home must ensure that all care staff members receive the minimum required level of formal supervision sessions of six per year. Requirements were made to ensure that all night- time care staff are involved in fire drills at least twice per year and the lift room door is locked. Also that a bathroom light is provided with a cover and a window repaired or replaced in one dining room.

CARE HOMES FOR OLDER PEOPLE Marlborough Court Care Centre 7 Copperfield Rd Thamesmead London SE28 8RB Lead Inspector Keith Izzard Unannounced Inspection 09:30 8 November 2005 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.V258877.R01.S.doc Version 5.0 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.V258877.R01.S.doc Version 5.0 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.V258877.R01.S.doc Version 5.0 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 10th May 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.V258877.R01.S.doc Version 5.0 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 by two Inspectors and lasted for 6.5 hours. The report should be read in conjunction with the previous inspection report for an unannounced inspection on the 10th May 2005 as some of the Standards were covered in that report. An additional visit to the home had been carried out by one of the Inspectors on 26th September 2005. This was in response to an Adult Protection concern, which had been raised in respect of one of the Service Users on the ground floor. The Inspector had spoken to several staff, toured the building, and examined relevant documentation concerning this. A report was made to the Company (as well as to the Adult Protection team), and this included 1 requirement, and 7 recommendations. The Company had made a positive response to all of the matters raised. The Inspector was pleased to see at this current visit, that those requirements/recommendations were either fully met, or in the process of being met. The Inspectors had talks with 12 Service Users; 2 relatives; the hairdresser; 2 health professionals (a GP and dietician); and 18 staff. These included the Administrator, an Agency Nurse, Unit Managers, care staff, housekeeper, domestic staff, maintenance man, chef, and activities staff. ( As well as the Acting Area Manager). Other staff members were seen carrying out their duties calmly and efficiently. Four care plans were examined on the ground floor unit; medication storage and administration on the ground floor; and four care staff files were examined. The system for dealing with finances for residents was examined and three individual files were found to be up to date with a good audit trail. What the service does well: The Company has responded well to requirements and recommendations, and shown a concern to provide good care. Staff members were welcoming and friendly, and one of the Service Users said that “the staff are very kind and look after me well.” The Inspectors thought the range of activities were good Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The Inspectors noted that although general health care was good, and preadmission assessments were reliably carried out, some of the Service Users had deteriorated since their admission, and were possibly out of category. There is a requirement to ensure that Service Users with increasingly high dependency needs are re-assessed, and placements are looked for in other units if necessary. If Service Users are not correctly placed, this has an effect on the adequacy of staffing numbers, and availability of equipment. Staffing levels must accordingly, be regularly reviewed to ensue the health and welfare of service users. Hoists were serviced on the day of the inspection. One of these failed the tests, and needs to be repaired or replaced. The Inspectors were also concerned that existing hoisting facilities may be inadequate, as staff had to wait for hoists to be transferred between floors at some times. There is therefore a requirement to review hoisting facilities generally, and provide these in line with the assessed needs of the residents on each floor. Medication procedures were generally satisfactory, but there were 3 items of concern. These have been identified in a requirement. Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 Page 7 The home must have a complaints log that clearly records progress, response and outcomes to complaints made to the home. Staff files were examined, and there was a good system in place. However, some new staff members did not have a recent photograph in place, and there is a recommendation to ensure that these are included. Mandatory staff training had been booked for all relevant subjects. The staff training matrix showed that some staff had not yet completed all required training, and there is a recommendation to ensure that all staff complete the required mandatory subjects and also that ongoing training is provided in dementia care. The home must ensure that all care staff members receive the minimum required level of formal supervision sessions of six per year. Requirements were made to ensure that all night- time care staff are involved in fire drills at least twice per year and the lift room door is locked. Also that a bathroom light is provided with a cover and a window repaired or replaced in one dining room. 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.V258877.R01.S.doc Version 5.0 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.V258877.R01.S.doc Version 5.0 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): 3, 4 & 5 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: The previous requirement to provide additional dementia training for the staff that are employed on the first floor unit had been implemented, however it is recommended that ongoing training in this area is given a high priority. The previous requirement to ensure that the home confirms the arrangements for admission in writing and provides information about the care and facilities provided prior to admission was complied with. Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 Page 10 All service users and their relatives are invited and strongly encouraged to visit the home prior to admission. Staff members and service users confirmed this information. All placements funded by Local Authorities are reviewed after the trial period. If an emergency admission is accepted staff obtain as much information as possible about the service users needs prior to admission. Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 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): 7-11 There is a suitable care planning system in place, and staff members have improved the quality and content of the documentation. Health care needs of Service Users are well met, with good input provided from other health care professionals. There are satisfactory systems in place for the effective management of medication administration. Service Users are treated with respect throughout their stay, and during the last stages of their lives. EVIDENCE: One of the Inspectors examined 4 care plans for the ground floor (nursing) unit. These included 2 care plans for Service Users with wound care, and the documentation had been considerably improved since the Inspector’s last visit in September 2005. Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 Page 12 Care plans are stored in individual folders, which are separated into different sections for easy access of information. Service Users’ personal details are followed by admission assessments. These include a falls risk assessment, nutrition assessment, pressure area risk assessment, moving and handling assessment, and continence assessment. Care plans are formulated according to the findings of the initial assessments, although some plans (such as one for personal hygiene care) are put in place for every Service User. Care plans are evaluated monthly, and this demonstrated that changes are made in the provision of care when applicable. For example, one Service User with poor general health had a more detailed nutritional care plan, and had food and fluid intake charts to keep a record of her nutritional intake. The Inspector looked particularly at the documentation of wound care. Each wound had a separate care plan so that it was possible to follow the progress in healing or deterioration of each area. These plans were evaluated every 2 –3 days, and showed appropriate action taken to address changes in the healing process. Daily records are written on individual residents by both care staff as well as nurses, and these had also improved since the last visit, with more detailed contents, and properly signed and dated. There is good input from other health professionals, who are contacted as necessary. During the inspection, a GP visited one Service User, a dietician visited to review several Service Users, and a Speech Therapist visited. Referrals are made to other health professionals when needed, such as Occupational Therapist, dentist, and community psychiatric nurses. A chiropodist visits the home, and District Nurses give nursing care to Service Users on the residential floors when required. It was apparent that some of the Service Users on the dementia unit needed to be reassessed, as their dependency levels had increased since their admission, and they may require EMI nursing care. There is a requirement to ensure Service Users are reassessed in the light of their changing needs, to ensure that the home is still able to meet all needs adequately. Requirement 1. Medication administration and storage were inspected on the ground floor. Storage is in a small clinical room that was rather cluttered, and would benefit from being better organised. Storage was in suitable locked cupboards, with external medication kept separate from internal medication. There was evidence of good stock rotation, except for one item. Eye drops had not been dated on opening, and this needs to be addressed. Medication Administration Records (MAR charts) showed that medication is checked on receipt from the pharmacy. The charts were generally well completed, but handwritten entries were not signed and dated. Controlled drugs (CDs) were properly stored; the Inspector checked one item against the entries in the CD register, and these tallied with each other. The drugs fridge was in satisfactory order, and the temperature is recorded daily. The Inspector noted that the clinical room did Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 Page 13 not contain an up to date British National Formulary (BNF) book, only an old 2001 “Mims” book. This is included in the requirement. Requirement 2. Service Users said that they were well cared for, and appeared to be well groomed, and appropriately dressed for the time of year. The hairdresser was visiting, and was busy carrying out hairdressing for a number of Service Users. Another Service User was seen having their fingernails trimmed by a carer. The admission forms include a section in regards to funeral arrangements, so that any specific preferences can be discussed at the beginning of the stay, and are then in place in the event of failing health or an emergency. Relatives are able to visit at any time, and are included in discussions where appropriate. Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 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): 12-15 The home has suitable arrangements in place for enabling Service Users to carry out their choice of activities. This includes good contacts with the community, and with relatives and friends. Dietary needs are well catered for, with the provision of a varied and balanced menu. EVIDENCE: The home employs an Activities Co-ordinator, who has an Assistant to work alongside her. They jointly work for 36 hours per week, providing good coverage for activities throughout the home. The Inspector was informed that they had just implemented a new programme of activities, which enabled them to build up friendships with Service Users, and to assess the activities most enjoyed by different people. Service Users are free to join in with group activities, or sit quietly on their own according to choice. One to one input is also given where possible. Activities are carried out at different times of day on each floor. Service Users on the dementia unit were seen enjoying taking part in an indoor ball game, while others were happy doing painting and drawing at the lounge table. The programme of activities includes other items such as watching videos together, Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 Page 15 keep-fit exercises, musical afternoons, bingo, and crafts. Service Users are taken out into the gardens or for walks, and are able to join in with local church coffee mornings as well. A local church carries out church services twice per month in one of the lounges of the home. The Activities staff members are very good at organising outings, and these might include trips to shows or theatre, or to seaside resorts. The Inspectors noted that sometimes these are for large numbers of Service Users, and a specialist coach is hired for the occasion. This could prove very difficult to ensure safety of all Service Users going out, unless there is one to one/one to two care available. The Inspectors recommend that the Company consider the purchase of a minibus, to enable groups to go out for outings more frequently, but in smaller numbers. Recommendation 1. Service users spoken at the previous inspection confirmed that they exercise choice and control over their lives. Standard 14 was not scored on that occasion, as it should have been, this has been rectified in this report and recorded as met. One of the Inspectors met the chef, who has many years of experience in catering for large numbers of people. There is a daily choice for main meals and desserts, and different choices for tea- time. Diabetic diets are catered for, and meals are pureed for Service Users as required. Care staff members take a daily list to the kitchen that indicates Service Users’ choices for the next day. The kitchen was in good order, even though it was just after lunch. There is a separate area for washing up, and the chef has a Kitchen Assistant to help with this. Food samples are taken daily in case of any concerns, and fridge, freezer and food temperatures are recorded daily. There is a controlled cleaning programme, and the kitchen appeared generally clean. An Environmental Health Officer had recently visited, and had made several requirements/recommendations in regards to some areas of flooring, and staff toilet facilities. These were already being addressed. Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 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 The previously reported dissatisfaction with complaints responses has been addressed. However, the home must organise the complaints log to show complaints in chronological order and be indexed. Retain copies of all relevant correspondence and recorded notes. The outcomes must be recorded clearly to indicate whether complaints were substantiated, partially substantiated or not substantiated and record whether the complainant was satisfied with the response. Systems are in place to ensure service users’ legal rights are protected and are protected from abuse. EVIDENCE: The complaints log was examined, however a number of documents were incorrectly filed, as they were not complaints. Other documentation was out of sequence and it was difficult to track the original complaint, the subsequent investigation and the response from the manager of the home, in some instances. In response to three complaints identified in the previous inspection report a number of requirements were made to do with recording and reporting of accidents, the management of medication, cleanliness of the building maintenance and health and safety checks and infection control procedures. These issues have been addressed, but a requirement to evaluate the complaints procedure has not been and is therefore restated. A requirement was made in this report that the home must organise the complaints log to show complaints in chronological order and be indexed. All Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 Page 17 copies relevant correspondence and recorded notes must be retained on the filer. The outcomes must be recorded clearly to indicate whether complaints were substantiated, partially substantiated or not substantiated and whether the complainant was satisfied with the response. See Requirement 3. All of the service users are included on the electoral register and are supported to vote. A couple of days prior to elections staff ask all of the service users whether they would like to vote. Those service users that wish to vote are escorted to the polling station, which is located in the school opposite the home. An additional visit to the home had been carried out by one of the Inspectors on 26th September 2005. This was in response to an Adult Protection concern, which had been raised in respect of one of the Service Users on the ground floor. The Inspector had spoken to several staff, toured the building, and examined relevant documentation concerning this. A report was made to the Company (as well as to the Adult Protection team), and this included 1 requirement, and 7 recommendations. The Company had made a positive response to all of the matters raised. The Inspectors were pleased to see at this current visit, that those requirements/recommendations were either fully met, or in the process of being met. Recent training had recently been provided in the prevention of adult abuse. 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 individually examined. Additionally the system is subject to spot checks at any time and an annual external audit. Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 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): 19-26 There has been a considerable improvement to the environment since the previous inspection. EVIDENCE: Ongoing maintenance and health and safety issues featured heavily in the previous inspection reports these have now been attended to, a previous recommendation that that the system for reviewing and monitoring these areas is reviewed has now been responded to. The maintenance log for the home was poorly maintained and has been improved to demonstrate that items are reported and checked/ monitored and dated. The home has now appointed a fulltime temporary maintenance/ handyman and is currently recruiting for a permanent member of staff. The Inspectors were impressed with the efforts made by the incumbent temporary handyman. This was also true of the improvements made since the permanent appointment of a new 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 Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 Page 19 system and other quieter areas where service users could meet visitors or socialise. 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 was answered promptly by staff. 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 an inspection of hoisting equipment on the day of inspection that the home needs to urgently review the provision of hoists as one was declared unfit for purpose and the availability of adequate hoisting facilities was the subject of a previous requirement, as yet unmet. Restated Requirement 4. 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 the home was clean pleasant and hygienic throughout and health and safety matters had been attended to. The inspectors noted that a fluorescent light in one bathroom required a cover, a window was badly fitting in one dining room and the lift room door was unlocked. Please see Standard 38 and Requirements 8,9 &10 Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 There had been some recent changes in management and staffing, which had brought about improvements in staff morale. Staff changes and additional recruitment were still ongoing. 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. Care workers must receive a minimum of six formal supervision sessions per year. EVIDENCE: The Inspectors asked senior staff on each floor about how many staff were usually on duty for each shift, and how this works out in practice in terms of carrying out their duties effectively. General staffing levels appeared to be satisfactory on the day of the inspection, although staffing rotas were not viewed at this inspection. However, the Inspectors noted that staffing can become insufficient, when there are increased levels in the deterioration of a number of Service Users at the same time. On the dementia unit, there are usually 5 care staff members in the mornings, 4 in the afternoons and 3 at night duty. These figures include the Unit Manager or Senior Carer for the shift. Some Service Users were developing mobility difficulties, or an increase in their dementia. This means that there are times when 3 staff members are needed to care for 1 person, and this only leaves one or two other staff to oversee up to another 26 Service Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 Page 21 Users. The Unit Manager had already identified one or two Service Users who should be reassessed, as they may need EMI nursing care. (This has already been referred to in standard 8.) Reviews of staffing levels must be under frequent review to ensure that there are sufficient numbers of experienced staff to provide care at all times. Domestic staff members were working hard to keep the home clean. The Housekeeper was carrying out laundry duties for a staff member on leave, and was also doing routine carpet cleaning. She was assisted by 2 other domestic staff, who cleaned all 3 floors between them every day. The home was in the process of recruiting another cleaner, so that there would be one per floor. The home was also in the process of appointing a maintenance person, and a staff member was acting temporarily in the role at this time. One of the Inspectors examined staff files, including 2 for newly recruited 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. Not all staff files included a recent photograph in accordance with the amended Schedule 2 in the Regulations. There is a recommendation to ensure these are included. Recommendation 2. 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 had recent training. For other mandatory subjects, there were numbers of staff still waiting for training, or for updates. There is a recommendation to ensure that all staff members receive mandatory training within the first 6 months of foundation training and provision of ongoing training in dementia care. Recommendation 3. A completed induction programme was viewed in one file, and this showed a detailed and comprehensive induction process. Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 Page 22 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): The home is run in the best interests of service users but efforts must be maintained to ensure regular meetings with service users and advocates/ relatives. The results of the recent survey of residents’ views must be published. Service user’ rights are safeguarded by the homes record keeping and policies and procedures and now much improved since the previous inspection. The health safety and welfare of service users are promoted and protected. EVIDENCE: Standards 31 & 32 were not assessed as the home is in the process of recruiting a new manager and the Inspectors were informed that this person would be appointed as soon as possible. However, it should be mentioned that following the departure of the previous registered manager the acting manager has managed the home in very difficult circumstances, and to her credit has Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 Page 23 managed significant improvements in responding to most of the requirements made at the previous inspection. The standard of the building, records and staff morale was much improved. This is commendable. 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. The responsible person for 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 money is retained. Additionally, the system is subject to spot checks at any time 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, however this now requires analysis and publication of the results in accordance with Standard 33.4. Requirement 5. A similar survey should be undertaken to canvass the views of professionals having contact with the residents of the home. Recommendation 4. It was evident that efforts were being made to reinstate regular meeting 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 unacceptably low and is again, the subject of a requirement. Restated Requirement 6 The responsibility for who supervises staff requires clarification within job descriptions and supervision training provided for those who undertake this task. Restated Recommendation 5. Overall, care record keeping had improved, however it was clear that records retained in respect of health and safety checks and maintenance checks were poor prior to the departure of the previous manager and the maintenance man, in fact some could not be located. This situation has now been improved considerably and the Inspector was satisfied that the new temporary maintenance man had performed well to address the previous shortfalls. A sample of records to do with health and safety and maintenance checks were examined and found to be comprehensive and well documented, subsequent to the departure of the previous manager and maintenance man. However, it was not possible to ascertain whether night care staff had been included in fire drills, this must occur at minimum twice per year. Requirement 7. Also the provision of hoisting equipment must be urgently reviewed to determine whether an adequate number are provided for the demand presented. Staff members interviewed stated that on occasions hoists were being shared between units causing delays and one was removed from service on the day of inspection because of mal function. Restated Requirement 4. The Inspectors noted that the fluorescent light fitting in the bathroom on the ground floor did not have a cover fitted, this should be addressed Requirement 8 and a window in the dining room of the first floor unit was Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 Page 24 badly fitting and should be replaced, Requirement 9. The lift room door was unlocked and therefore a potential hazard to residents. Requirement 10. The maintenance man agreed to address this issue and a cover for the light immediately fitted. Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 Page 25 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 1 3 2 Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 Page 26 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 14 (2) Requirement Timescale for action 31/12/05 2 OP9 13 (2) 3 OP16 17 To ensure that service users with increased dependency levels are reassessed to ensure that the home is still suitable to meet their needs. Eye drops must be dated on 31/12/05 opening. Handwritten entries on MAR sheets must be signed and dated for accountability. The home must have an up to date copy of the British National Formulary (BNF) easily available for staff. The complaints log must show 31/12/05 complaints in chronological order and be indexed. Retain copies of all relevant correspondence and recorded notes. The outcomes must be recorded clearly to indicate whether complaints were substantiated, partially substantiated or not substantiated and record whether the complainant was satisfied with the response. Ensure an urgent review of hoisting facilities within the DS0000006766.V258877.R01.S.doc 4 OP22 23 n 31/12/05 Marlborough Court Care Centre Version 5.0 Page 27 5 OP33 24 (2) 6 OP36 18 (2) 7 OP38 23 (4) e 8 9 10 OP38 OP38 OP38 23 p 23 (2) b 13 (4) a home to ensure adequate provision. Restated: previous timescale of 1.03.05 not met. The survey of residents’ views regarding the running of the home and the service provided must be published. Care staff must receive formal supervision sessions at least six times annually. Restated: previous timescale of 1.09.05 not met. Ensure that all night- time care staff members are involved in at least two fire drills per year and this is recorded. The fluorescent light in the bathroom on the ground floor has a suitable cover provided The window in dining room first floor is replaced or repaired. The door to the lift room must be kept locked to safeguard residents from hazards. 01/02/06 31/12/05 01/04/06 31/12/05 01/03/06 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP12 OP29 OP30 OP33 OP36 Good Practice Recommendations Consideration be given to providing a mini bus for the home to further facilitate outings for residents in smaller numbers. A recent photograph of all employees should be included on their personal file. All staff should receive mandatory training within the first six months of employment and ongoing training provided for those staff particularly on the dementia care unit. A survey of the views of professional visitors to the home should be undertaken as part of quality control measures. Clarification is needed as to whom is responsible for care staff supervision and training to supervise provided for DS0000006766.V258877.R01.S.doc Version 5.0 Page 28 Marlborough Court Care Centre these individuals. Marlborough Court Care Centre DS0000006766.V258877.R01.S.doc Version 5.0 Page 29 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.V258877.R01.S.doc Version 5.0 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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