Inspection on 12/07/07 for Marlborough House Nursing Home

This inspection was carried out on 12th July 2007.

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

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

Other inspections for this house

Marlborough House Nursing Home 22/06/06

Marlborough House Nursing Home 13/02/06

Marlborough House Nursing Home 12/02/05

Marlborough House Nursing Home 16/11/04

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

CARE HOMES FOR OLDER PEOPLE Marlborough House Nursing Home 241 Aldershot Road Church Crookham Fleet Hampshire GU13 0EJ Lead Inspector Jan Everitt Unannounced Inspection 12th July 2007 09:00 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 House Nursing Home DS0000012228.V341242.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 House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marlborough House Nursing Home Address 241 Aldershot Road Church Crookham Fleet Hampshire GU13 0EJ 01252 617355 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) Craysell Limited Mrs Jane Ratchford Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (47) of places Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Only 27 service users can be accommodated who are in receipt of nursing care at any one time Only 20 service users can be accommodated who are in receipt of personal care at any one time 19th January 2007 Date of last inspection Brief Description of the Service: Marlborough House is a nursing home providing nursing and personal care for up to 47 older people. The home is owned by Craysell Limited and it is located on the outskirts of Fleet and close to the village of Church Crookham and the local amenities. The establishment comprises of 2 buildings that are linked on the ground floor. One part is a large house that was converted for use as a care home and there is a newer purpose built extension. Both parts of the building have 2 stories and most residents requiring nursing care are accommodated in the extension where all rooms are single and benefit from having en-suite facilities. There are a number of double rooms in the older part of the building that mainly accommodate service users who require personal care and most of these rooms do not have en-suite facilities. The home has a garden that can be accessed by wheelchair users. There are a range of communal rooms throughout the establishment and there is a passenger lift in the extension and a chair lift in the older part that provides access to the first floors of each of the respective parts of the home. The fees at the home range between £529 - £730 for those who need nursing care and £335.23 for residential care. These fees do not cover hairdressing, chiropody and other personal items. Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site inspection visit to Marlborough House, which was unannounced, took place over a one-day period on the 12th July 2007 and was attended by one inspector. The registered manager, Mrs. Jane Ratchford assisted the inspector throughout the visit and was available to provide assistance and information when required The visit to the home formed part of the process of the inspection of the service to measure the service against the key national minimum standards. The provider had returned the Annual Quality Assurance Assessment (AQAA) to the CSCI and the focus of this visit to the home was to support the information stated in this document and other information received by the CSCI since the last fieldwork visit, which was a random inspection, made to the home in January 2007, which followed the key inspection of June 2006. Documents and records were examined and staff working practice was observed where this was possible without being intrusive. The inspector toured the home and spoke to residents, visitors and staff in order to obtain their perceptions of the service the home provided. Those spoken to were generally satisfied with the care and services that were being provided. Surveys had been distributed to service users, relatives, care managers, GP and other visiting professionals. Eleven service user surveys and four relative/carer surveys were returned to the CSCI. The inspector spoke with one relative over the telephone. No surveys were received from those sent to visiting professionals or care managers. The outcome of the surveys indicated that there was an adequate level of satisfaction with the services and that generally residents and relatives were pleased with the home. At the time of the inspection the home was accommodating 35 residents, a number of which were unable to communicate effectively with the inspector to gain their views of the service. There were no residents from an ethnic minority group. The owner of the home visited whilst the inspector was in the home. He discussed the proposed structural alterations he wishes to undertake on the older part of the building to provide modern accommodation that meets the current standards. The newer part of the home will then be refurbished. The logistics of this large project is proving difficult for him to plan, and there have been delays on the work commencing, hence the requirements identified in this report that surround the environment. Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 6 What the service does well: The AQAA states that what the home does well is to pre assess all service users that are referred to the home to ensure the placement is appropriate and the home can meet their needs. They and their relatives are invited to visit the home before any decisions are made. An information/welcome pack is in all service users’ rooms, which contains the statement of purpose and service user guide. The site visit, talking to service users and their relatives, looking at records demonstrated that this does take place. The AQAA details how service users health and personal needs are identified and met by the primary health care team and other visiting professionals. This was demonstrated in the care plans and records and speaking to service users and relatives. Service users commented that: ‘ staff are friendly and helpful’. ‘Always listen and are helpful’. ‘Staff are usually available when I need them but sometimes they are busy elsewhere’. ‘I usually get the care and support I need’. Comment cards reported that the service users do receive the medical support they need. The AQAA reported that the home has a varied weekly programme of activities. This was demonstrated in the weekly programme that was advertised and service users spoken to and surveys returned showed that there were activities available in the home most days of the week even if some service users did not choose to join in or preferred their own company. Meals are nutritious and healthy. The catering service responds to service users dietary needs and wishes. A small number of service uses made negative comments about the food when speaking to the inspector, but the majority reported satisfaction with the food. The comments from the surveys returned, indicated general satisfaction with the meals. Service users and relatives feel able to make comment or complain to members of staff or the manager and know they will be listened to. This was supported by the inspector speaking to relatives and service users and the comments received on the surveys indicated awareness of the complaints procedure. The deputy manager has created a weekly training programme for staff. This was demonstrated by the adverts on the wall the speaking to staff who report they have a wide range of training available to them that appertain to the client base they care for. Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: The registered person must provide to all service users, a contract of terms and conditions of residency, which should be signed by them or their representative. The registered person must ensure that all senior management staff are familiar with the safeguarding adults reporting procedures. The registered person must ensure the safety of the service users by making sure that all bedrails that are in use on resident’s beds are covered with a protective bumper to prevent the risk of entrapment. The registered person must ensure that all parts of the home are in a good state of repair and that a programme of renewal of the fabric and decoration of the premises is implemented. One service user commenting the ‘The home needs upgrading and being more organised for the amount of money that is being charged’. The registered person must ensure that all parts of the home are clean and hygienic and that the home is free from offensive odours. The dignity and respect of service users must be maintained at all times and staff must not leave commodes in eating/communal areas. The registered person must establish a system for quality assuring all aspects of the service and this includes seeking the views of service users and other stakeholders to enable them to identify levels of satisfaction and areas for improvement. The registered person must ensure that systems are in place for staff to receive supervision at least six times a year and records maintained of these meetings. Service users should have input into the development of the menus and make suggestions as to what alternative menus they would like made available to them. Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 8 A training matrix could be developed by the deputy manager to enable him to easily identify the training that has taken place and by whom. The manager should review the Statement of Purpose to reflect the change of policy to a ‘No Smoking’ home. The manager should be aiming to recruit staff that have the NVQ level 2 qualification or encourage her existing staff to undertake this qualification to enable the home to meet the standards. 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 House Nursing Home DS0000012228.V341242.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 House Nursing Home DS0000012228.V341242.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): 2&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Not all service users/representatives have signed contracts of agreement of the terms and conditions of service users’ residency. Service users are comprehensively assessed prior to admission to the home to ensure the home can meet their needs. EVIDENCE: The inspector selected the personal files of four service users to view the contracts of residency. One contract had been signed, one had not been signed and the other two were waiting to be returned from relatives signed. One service user spoken to confirmed that he had signed a contract when he came to the home to live. Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 11 The AQAA stated that all service users are assessed prior to their admission to the home. Relatives and service users are invited to visit the home prior to admission. This was confirmed by a relative survey that said, ‘We had two visits before admission’. Another relative commented that ‘I went round every home and chose this one as I thought it the nicest’. On admission service users receive a welcome pack in which the Statement of Purpose is contained. The inspector observed the Statement of Purpose in all service user’s rooms. The inspector viewed a sample of 4 service user’s care plans in which the preadmission assessment is kept. The manager has recently reviewed the content of the assessment tool. A more recent assessment viewed by the inspector was observed to be comprehensive and detailed and would be sensitive to a person’s physical and social care needs. The assessment tool is based on areas of need set out in paragraph 3.3 of the National Minimum Standards for Care homes for Older People (NMS). The service users and relatives spoken with at the time of this visit, confirmed that the manager had been to see the service user in hospital or in their own homes, prior to coming into the home to live and that they had been provided with sufficient information to enable them to make an informed choice. Relatives told the inspector that if possible they are involved with the preadmission assessments. Service users spoken with confirmed that they felt their needs could be met by the home. Marlborough House Nursing Home DS0000012228.V341242.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 good. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs are set out in individual care plans. Health needs are fully met. The home has clear policies and procedures in place regarding the administration of medication. Residents feel that they are treated with respect and dignity by the staff and management of the home. EVIDENCE: The AQAA records that each resident has a key worker and this was demonstrated on the notice board in the staff room and is also on a notice in the service users’ rooms. The AQAA stated that residents and relatives are involved in the care planning process and indeed there was evidence in the care plans of them being signed by the service user or the relative. Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 13 The records of 4 residents were examined and these documents included the plans of care that had been developed for the individuals following the pre admission assessment and admission to the home. In all the plans seen there were general risk assessments in place as well as specific assessments of the nutritional needs of the person concerned and the risk of pressure sores. Strategies for eliminating or reducing the risk of harm had been identified and implemented e.g. pressure-relieving aids were in place. Where an individual had a PEG to deliver nutrition and fluids there was a plan for this individual and action to be taken by staff. The inspector did identify that in one service user’s file, weights were being recorded regularly, although the risk assessment had not identified a risk. However, the regular records of weight indicated a gradual, but substantial weight loss over a period of two months, which had not been identified as a risk and therefore not addressed. This was discussed with the manager. The manager told the inspector that relatives had been asked to be involved in giving life histories and contribute into drawing up an appropriate social care plan. The inspector evidenced an interesting life history, written by a relative in one of the care plans examined. The manager said that some relatives were reluctant to contribute to this, and therefore the response had been quite disappointing. The care plans seen on this occasion did set out the actions staff had to take for those needs that were identified and what specialist equipment was needed to provide the support and assistance each service user requires. The AQAA states that the home is implementing ‘end of life’ care plans. This will be based on guidance from the Gold Standard Framework for Palliative Care. The inspector did not evidence this in the care plans viewed. There was documentary evidence that care plans are reviewed monthly or if the resident’s condition changes. Daily records were available for the 4 individuals whose plans were seen. Nursing and health care assistants spoken to were aware of the contents of the care plans that were sampled and the assistance that the individuals concerned required. The AQAA reported that over the next year the home anticipates continual improvements in care planning and that the home will ensure that documentation would address all aspects of the person. The AQAA states that all service users are registered with a GP, and are seen regularly by them. Service users also have access to opticians, dentists and chiropodists. A service user spoken to did not have dentures and explained to the inspector that she has been to see the dentist regularly but to date he has been unsuccessful in supplying her with a suitable denture. All medical appointments are recorded with the outcome in the care plans. Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 14 The service users spoken to report that they see a doctor when necessary if they are not feeling well. A relative spoken with said that her mother receives all the medical support she needs. The home is visited by the speech and language therapist to monitor the one service user who has a PEG fitted for feeding. The inspector evidenced the instructions left by the therapist on the feeding regimen. The AQAA states that there has been an increase in close working with outside specialists such as SALT and physiotherapists. One comment from a relative says that ‘mum is fed up of sitting in the chair with no physiotherapy’. The disciplines allied to health are only available to service users if they have been referred by the GP and assessed as needing therapy. The home had written policies and procedures available that were concerned with the management and administration of medication. Records examined included those concerned with the administration; ordering; receipt; and disposal of medicines, and all were accurate and up to date. There were controlled drugs being kept in the home at the time of the inspection and sedatives the home managed as if they were controlled drugs. A check of these was made and the balance of medication held was correct. The nurse responsible for the ordering and management of the medications was spoken with. She reported that the home has recently changed to a pharmacist who supplies MDS system and this is ‘working well’. She described the ordering process for medicines and reported that she sees and checks all prescriptions before they are taken to the pharmacist for dispensing, as stated in the Royal Pharmaceutical Society good practice guidelines. The inspector observed the trained nurse distributing medication. This was being undertaken following the correct safe procedures. The MAR sheets were being recorded appropriately and reasons documented why medications were not being taken or refused. The medications were stored in three locked and secure medicine trolleys. The inspector observed that the trolley stored on the first floor in the hallway was not secured to a wall or in a locked environment. This was highlighted to the manager immediately and the maintenance man was called to attach a bracket to the wall for security and this was completed by the end of the visit. The inspector viewed the ‘clinic room’ in which dressings and other medication stocks were kept in locked cupboards. There was no evidence of over-stocking of medications. A medical refrigerator was also used for medicines requiring special storage conditions. The temperature of the refrigerator was regularly checked to ensure that it was working effectively. Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 15 Medicines being dispensed from their original containers were dated when they were opened/started. The home has one service user who is self-medicating her own inhalers. The inspector discussed this with the service user who was obviously capable to keeping these in her own room securely. The MAR sheets evidenced that these inhalers were being self-medicated. There are lockable storages areas in each room should a service user wish to self medicate. The manager told the inspector that at the current time there is no necessity to administer medication covertly to any service user. She described to the inspector the procedures she would follow should this be necessary by discussing the problems with the GP and pharmacist and also any relatives involved. The inspector observed that staff were treating residents with respect and dignity. Personal care was carried out in private and the staff knocked on doors before entering. Service users are also able to maintain their own door keys and some residents were choosing to keep their doors locked whilst they were not in their rooms. Residents spoke highly of the staff and said that they feel they are treated with respect. One comment received on a survey was that ‘staff take a lot of thought and care about individual people’. The home had recently received a complaint from a service user with regards to what, he considered, to be being treated with disrespect by a carers. The management and his care manager have addressed this. The home is respecting his wishes and the carer does not work with this resident any longer. Marlborough House Nursing Home DS0000012228.V341242.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, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a range of social activities in the home. Family and friends are encouraged to visit the home and maintain contact. Residents are helped to exercise choice in their lives. The home provides residents with a choice of well-balanced food however, this is not advertised and therefore some residents are unaware of alternative meals. EVIDENCE: The home employs a person solely to organise and undertake activities in the home. She attends the home five days a week. The inspector observed an activities programme being displayed. The programme demonstrated a variety of group games, quizzes and for those residents who have communication difficulties, and one to one discussions, individually in their rooms. Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 17 The AQAA reports that the activities organiser maintains a diary of events and of the service users who are seen individually. At the time of this visit there was a large group of residents playing musical bingo and the group proved to be very jolly and everyone was participating. The inspector observed the activities organiser was very good at interacting with the service users and giving them time to play the game. The surrounding gardens have seating areas and one service user likes to sit in the garden whatever the weather. This same service user, who had loved gardening in the past, had, with assistance, planted a number of containers for the patio that were looking splendid and full of colour. He reported to the inspector that he loves his garden and enjoyed the planting and end result. On the day of this visit a number of service users were using the garden. Comments from most of the service users on the surveys indicated that they ‘always’ or ‘usually’ take part in the activities going on in the home, but some other comments were; ‘unable to participate’, ‘the family know there are activities that take place but mum does not wish to take part’, ‘I am not keen on group activities, I am a loner’. The AQAA records that the home tries to promote culture or religion and ministers of all denominations are available to visit the home if requested. The manager reports that the service users do not go out into the community very often and then it is only with relatives. The ‘Lions Club’ provide a shopping trip at Christmas time for those who wish to and are able to go out. If a service user has to attend an out patients appointment an escort will be provided by the home. Service users spoken with appeared content and did not show any desire to go out saying ‘ I am quite happy here and do not want to go out, the weather is so bad’. One service user spoken to does go out independently to the local shops. The deputy manager undertook a risk assessment and the resident was assessed as being safe to go out to the shops independently. Another resident is taken to the bank weekly by the activities organiser to enable him to manage his own finances. Visitors spoken to at the time of this visit told the inspectors that visitors are welcome in the home. The visitor’s book reflected this with many visitors signed in each day. Residents confirmed that they are able to exercise choice over such things as what time they get up, what activities they take part in, what they eat and what they wear. Food preferences are recorded and the chef is aware of likes and dislikes. Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 18 There was evidence that residents have the opportunity to furnish their own bedroom accommodation if they choose to do so and several residents spoken to said they had items of their own in their rooms and appreciated being able to personalise their bedroom accommodation so that it was “like home”. Items seen included tables, dressers, lights and television and audio equipment. The inspector visited the kitchen. The chef has been recently employed and he told the inspector that he is enjoying his job and has had a lot of experience in working in care homes for the elderly. The inspector observed the kitchen was clean and well organised as so were the store cupboards. Information about the needs of service users with specific dietary requirements was readily available in the kitchen e.g. diabetic, soft, chopped etc. Pureed meals were provided with all their constituents prepared separately ensuring that their appearance was attractive. The chef told the inspector that he would research and produce any special dietary needs of a service user whose religious or cultural beliefs dictated this. The chef stated that he has created a new menu that is now more seasonal. The inspector observed that the chef had cooked cakes for tea, which he reports, is a daily occurrence. The inspector observed the lunchtime meal being served and it was well presented. Service users spoken to said ‘The food is very good’ ‘There is too much of it, the food is excellent’. ‘I enjoy the cakes’ Residents who were relatively active said they knew what the main meal of the day was because they could see the menu that was prominently displayed, or they could go and ask the chef. All commented that if they did not like the meal that was on the menu there were other options, which were not advertised on the daily menu. ‘ You can ask for something different if you do not like what is being served’. One service user spoken to did not like the food and had been unable to eat his lunch. He had said he did not like it and had been offered a vegetarian option. This had disgruntled him and he had professed to keep his own supply of food in his room for instant snacks. A relative spoken to report that her mother had been offered a vegetarian slice when she did not like what was on the menu. Also it was commented by a relative that there is no fresh fruit supplied to residents. The service user surveys returned indicated that six residents ‘usually’ liked the meals, two ‘always’ and one ‘sometimes.’ There was one comment, stating ‘the meals can be monotonous’. Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 19 The manager must encourage residents to have their opinions and input into the menu planning and perhaps a suggested alternative meal be stated on the menu from which service users can choose before their meals. Some service users choose to eat in their rooms and some in the home’s dining rooms. Staff were observed sensitively and appropriately providing help to those service users that needed assistance at meal times. One resident has nutrition and fluid through a tube and it was seen that staff had full instructions as to how this was to be carried out for the individual and staff spoken with knew these instructions. Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 20 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are confident that any complaints they have will be listened to and acted upon. The home’s policies, procedures and staff training should ensure that, as far as possible, residents are protected from abuse. However, the lack of bumpers on bedrails could pose risks to service users. EVIDENCE: The home does display a copy of the complaints procedure in the main reception area. A copy of this is also contained in the information pack service users have in their rooms. The inspector viewed the complaints log, which records complaints and the action and outcome of any complaint. The AQAA records three complaints made in the last twelve months, of which two have been resolved and the third one is awaiting an outcome. The complaints made have been recorded and the outcomes documented where completed. The inspector viewed a letter the manager had written to a complainant in reply to their complaint. Service users spoken to are aware of how to complain. The manager had recently received a complaint from a service user. Another service user said Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 21 he had complained about not being able to go out alone and this has been resolved. Two relatives spoken with both said they would address any issues with the manager at the time that they arose. One saying ‘I am very up front and go to the manager to sort things out and this resolves things well’. The other relative said she had ‘been to the manager with a complaint but it had taken a few times of complaining about the same issue to get things resolved’. In general, the results of the service users surveys received indicate that service users know how to complain and one saying ‘I will speak to whoever is in the office’. ‘I will complain to the first member of staff I meet and they pass it on if necessary’. The home has the Hampshire Adult Protection policy and procedures in place for the reporting of abuse. The home has had one adult protection incident in recent months reported to Social Services concerning an agency staff member and two service users. The outcome identified that procedures were not followed promptly by the delay in informing Social Services of the adult protection issue for one service user and a second occurrence happened before it was reported officially and action could be taken. The issue of this not being reported, as per policy, has been addressed with the deputy manager who is more aware of his role in reporting such incidences. The adult protection issue has now been addressed with the agency and the carer. The manager undertakes training the staff in safeguarding vulnerable adults, Staff spoken to were aware of the whistle blowing policy. The inspector observed that for service users who had bedrails in use, these had been risk assessed and signed permission sought for their use. This was evidenced in two of the four care plans viewed by the inspector. The inspector observed that not all bedrails had bumpers as protection and to avoid entrapment. Marlborough House Nursing Home DS0000012228.V341242.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 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s bedroom accommodation is furnished and equipped satisfactorily for residents needs. There were adequate systems and procedures in place to ensure the bedroom accommodation is both safe and comfortable. However, there are areas of the home that are in need of refurbishment and repair. There are areas of the home that are not clean and hygienic. EVIDENCE: A random inspection of this home was undertaken in January 07 following the inspection of June 06 at which time requirements were made around the cleanliness and safety of the environment. At the time of the random inspection it was judged that the requirements had been complied with and no further requirements were made. Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 23 At this site visit the inspector toured the building with the manager. The home is divided into two parts one being more recently built than the other and the old part is used for the residential and some nursing clients. There are areas of the home that are in urgent need of redecoration and refurbishment. The provider spoke with the inspector and reported that he wishes to extend the old part of the home and refurbish the whole home, but it keeps being delayed owing to the logistics of how this will be done with residents still living in that part of the home. This has been identified in previous reports and has been discussed since 2005. The AQAA states that the refurbishment of the home will commence within the next year and concedes on this document that what the home could do better would be to improve the physical structure both internally and externally. At the time of this visit there were thirty-five service users in residence leaving twelve empty beds. The inspector viewed most rooms. Some that were empty were full of furniture and equipment and in need of redecoration and not fit for purpose. Two were being made ready for potential clients. The AQAA reported that the rooms are decorated and re-carpeted before a new service user is admitted. The inspector noted that a new carpet had been fitted in one room but the decoration had not been done and one wall was stained. The general appearance of the older home was tired looking and in need of attention. The inspector observed that the first floor lounge/dining room on the residential side of the home housed a commode. This was pointed out to the manager. The inspector considered that this did not represent the home respecting the dignity of service users having a commode in the same room as they were expected to eat. The manager had it removed immediately. This dining/lounge area was in need of redecoration with a large stain on the ceiling, and generally looking in need of attention. The inspector visited one double room, which was unoccupied at the time, this was in need of redecoration and the two divan beds in the room were so low that they would have presented a moving and handling risk for staff bending to assist residents from the bed. In this same area, a double room visited had a strong offensive odour as the door was opened. This was pointed out to the manager, who immediately instructed the maintenance man to shampoo the carpet. Both beds had bedrails in place but with no bumpers in position. The room had an en-suite facility with a washbasin that was small. The inspector observed two hand bowls in this toilet that were used for washing the two residents, they were dirty with marks around the edge of the bowl and did not look hygienic and conducive to infection control practices, besides being a representation of poor practice and lack of respect for the service users who were expected to use them. This was discussed with the manager who summoned one of the cleaners to scrub the bowls. Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 24 The bathrooms in this part of the home are internal with no windows and have extractor fans that were observed to be very dirty and not working properly. The maintenance man said that the fans did need some repair. Three of the four bath chair hoists were not working properly, leaving just one bathroom serviceable for this part of the home. The administrator reported that when the company came to service the hoists, they could not repair these hoists because of their age and that they were planning to replace them. The representative called at the time of this visit and the provider anticipates replacing one and the others to be repaired. Service users spoken with said they were happy with their accommodation and the inspector observed that many had made their rooms very homely. Members of family spoken to said they were happy with their relative’s rooms. The AQAA states that all housekeepers have an induction on how to maintain the cleanliness of the home and their commitment could be improved. This was discussed with the manager who reported that she does have some constant staff but the housekeeping staff are transient and change frequently. The administrator has taken over the monitoring of the ancillary staff to identify areas for improvement. One relative spoken to over the telephone said that she had made a complaint to the manager about the cleanliness of her relative’s room and that it had been resolved but she does monitor the standards. Comment on the surveys mostly ticked that ‘usually’ the home is fresh and clean but several service users and stakeholders allude to the standard of cleanliness in the home with comments such as: ‘Mum thinks is it fresh and clean but the family say it is not’. ‘Cleaning needs to be done on a routine basis not now and again and sometimes it smells of urine when you walk down the corridor. Had to complain and get the carpet shampooed and I should not have to do this.’ ‘Food tables in rooms are not washed or wiped regularly’. The inspector visited the laundry and spoke to the laundry person. She was knowledgeable about her job and how to handle soiled linen and the infection control measures to take. The inspector observed that some of the sheets being used were very thin and this was identified to the manager. Laundry machines were available and they had settings to manage soiled articles and hand washing facilities were there for staff to use. There are two sluices in the home for staff to use to clean commodes. The kitchen was visited and the air conditioning unit remains broken and this was highlighted at the previous inspection visit of January 07 where it was stated that the issue would be addressed when the refurbishment takes place in Spring 2007. This has not happened and the unit is still out of service. Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 25 The surrounding gardens are pleasant and the pond area has been filled and made into a rockery area that now does not present any risks to the service users. A requirement from the June 06 report was that the hot water temperatures were too high. The hot water temperatures are now being monitored by the maintenance man monthly, and the records were shown to the inspector and demonstrated that the hot water emitting from the taps is at a safe temperature being recorded as below 43 degrees. The home has a separate housekeeping staff and two were on duty on the morning of this visit. The inspector observed that the housekeeper did not leave her cleaning equipment, which contained COSHH chemicals, unattended. The cleanliness of the home was better on the newer side of the building, where it appeared less cluttered. The staff training files evidenced that staff do undertake infection control training. Hand washing facilities and disposable towels are available throughout the home. Staff were observed to be washing their hands and observing infection control principles when dealing with service users. Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 26 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, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides adequate staffing. The home provides staff with a varied training programme appertaining to the people who live in the home in order to meet resident’s needs, however staff are reluctant to undertaken formal training and therefore 50 of care staff are not NVQ level 2 trained. The recruitment policy and practices safeguard the people who live in the home, however a full induction programme is not documented as being provided to all newly recruited staff. EVIDENCE: The AQAA stated that the home maintains a daily work rota, which shows where staff are allocated, and that the number of care staff on each day is dependant on the number of service users in residence. At the time of this visit the home was accommodating 35 service users, 27 nursing clients and 8 residential. The staffing on duty were 2 RGN, 4 carers, the manager, 2 housekeeping staff, 2 kitchen staff, the maintenance man and the activities organiser. The staffing levels remain the same throughout the day with Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 27 1 RGN and 4 carers on duty at night. The home was adequately staffed for the number of service users in residence. Service users were observed not being rushed through their daily routines. Observation and discussion with residents at the time of the visit, confirmed that individuals receive the help they require in a timely way and that the equipment was in place to support their needs. Conversely, two of the eight service users who returned surveys commented that the response to their needs and the help they receive is dependant on how busy staff are elsewhere, with one comment ‘it can seem slow but staff are busy elsewhere’. ‘It depends on the number of residents needing the limited staff’. The manager told the inspector that she and the deputy manager promote training and especially the NVQ level 2. Some members of staff are eager to undertake this training but must first attend language classes to enable them to understand the written language. The manager reports that the staff group are predominately from ethnic minorities and a large number from eastern European countries, who have a problem with understanding how to write English. At the time of this visit there home had 15 of care staff with NVQ level 2. The inspector spoke to the deputy manager who has responsibility for the training programme. He himself has a teaching qualification and is eager to educate staff. The home has a weekly teaching programme on various subjects that appertain to the client group they care for. These include, Dementia, Care of Ageing Skin, Death and Dying, Catheter Care Nutrition, Food Hygiene, Infection control, Moving and Handling, (however, this is only the theory aspect of this mandatory training as the practical training is provided by an outside training provider). Each training session is followed by a question and answer paper to test the knowledge gained by the attendees. The deputy also does this to ensure that the foreign staff understand the content of the training. The deputy plans the training programme six monthly so that staff have time to arrange to attend. These are advertised on the notice board in the staff room. He reports that these sessions are well attended. The training records are not captured on an electronic matrix. The records are maintained with the deputy manager in separate files. A recommendation will be made that a training matrix be recorded to ensure easy access to records of what training has taken place and who has attended, thus ensuring that all staff are attending the required mandatory training. The deputy manager evidenced in records that night staff do attend the training. Staff spoken with confirmed that they consider their training needs Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 28 are met and that they have plenty available to them. The company fund staff training. The manager reports and the AQAA states that all new staff undergo an induction period and receive an induction pack. Evidence of two induction programmes was viewed by the inspector, one being of a recently employed person, and another who had commenced in February 07. Neither of them had been completed. The inspector viewed a sample of four personnel recruitment files. The recruitment practices and procedures are robust with all information required found to be in place Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 29 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s manager has the experience and skills necessary to run the home effectively. There are good systems in place for safeguarding residents’ financial interests. There are basic systems in place for obtaining the views of interested parties about the quality of the service provided by the home, however these would not measure success in meeting the stated aims and objectives, and statement of purpose of the service. Staff are not formally supervised at regular intervals. The health and safety of the service users and staff is protected Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 30 EVIDENCE: The registered manager is a registered nurse and has been in post for a number of years but has not gained her registered manager’s award. She has no intention of undertaking this qualification as she is in the process of relinquishing her post as the manager but remaining part time with the company. She is eager to hand over to a new manager and is prepared to stay at the home for a handover period. On the day of this visit she and the provider were provisionally interviewing a person for the post of manager. The provider reports that he has not had much success in recruiting a suitable person. The manager said to the inspector that she is ready to leave the post but still stay involved with the company on a part time basis overseeing all three homes in the group. The manager is popular and respected and many of the relatives came to the office on their way in or out of the home to chat about their relatives. The inspector observed the manager comforting and interacting well with a relative who was upset at her father’s deteriorating condition. The home has currently no formal quality assurance system. The AQAA states that a quality assessment audit is in the process of being implemented. The home is introducing a ‘four star’ system to cover all aspects of the service, which will in future inform the information stated in the AQAA and this will evidence whether the home is meeting the standards. The AQAA states that quality assurance questionnaires are given out yearly to service users but the inspector could not evidence any results or outcomes from this. The manager reports that ‘service users do not return them very often’. Hence there is no documented feedback from the service users as to the level of satisfaction they have with the service. The AQAA states that all policies and procedures have been reviewed in 01/07 and are available to all staff, a set of which are stored in the staff room. The AQAA states that the home has a policy on diversity and discrimination. Staff are multinational and it states the home makes every effort for these workers to settle into the English culture and language, therefore the level of understanding of the policies for the staff, who find it difficult to comprehend written English, must be considered and provision for them be made, to ensure they understand how to work within the policies and procedures that underpin practices in the home. The home has established a no smoking policy in line with recent legislation and although care homes are exempt from this, the home has chosen to make the home a ‘No Smoking’ area. This was discussed with the manager as to the provision for one resident who does smoke and has been a resident for a considerable time. Provision for this person has been made. The inspector Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 31 discussed with the manager that the Statement of Purpose and Service User Guide must be reviewed to reflect this change in policy to ensure that future potential residents are aware that Marlborough House is now a no smoking home. Service users do manage their own money if they are able. One gentleman spoken to was waiting for the activities coordinator to take him on his weekly trip to the bank to organise his finances. Another resident told the inspector that he goes to the shops to buy his ‘tuck’ when he wishes to do so and manages his money. The administrator oversees the management of some service users monies and the inspector evidenced the records for a sample of two accounts. Monies are maintained in a locked environment and records were kept of any expenditure or deposits of additional monies (i.e. incomings and outgoings). Records were accurate and up to date. The deputy manager reported that supervision and appraisal takes place for all staff. The inspector could not find records of formal, regular supervision of staff in three of the four personnel files viewed. A requirement will be made from these findings. The administrator for the home is now responsible for ensuring that the servicing of equipment and systems in the home are undertaken at appropriate intervals. The inspector viewed a sample of servicing certificates and these demonstrated that all servicing is current. These included: • Fire safety equipment • Boilers and central heating • Hoists and slings • Lifts • Portable electrical appliances The home has a fire risk assessment, which was dated August 06. In discussion with the manager she is aware of her responsibility to ensure the fire safety of the home is in line with the recent fire regulations that have been published. The fire log was viewed and this demonstrated that the fire alarms are checked at appropriate intervals and that regular fire drills are carried out, at which time all staff on duty are recorded and this is considered part of their fire training each year. The training records evidenced that fire training for staff does take place and is recorded, but in the absence of a training matrix, it was difficult to identify if all staff had undertaken the training at least once a year. The inspector spoke to the maintenance man who was able to evidence the records of water temperatures that are checked monthly throughout the home. These demonstrated that the hot water emitting from hot water taps is now within safe temperature parameters. The random inspection of January 07 had Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 32 established that this requirement had been complied with from the previous key inspection of June 06. There was evidence from both discussion and records that most staff working in the home had received some training in health and safety subjects that were relevant to their role in the home. These included first aid, fire safety, food hygiene, moving and handling, infection control and control of substances hazardous to health. All accidents are recorded. The inspector viewed the accident book. The details of each accident are not being stored in personal files in line with the Data Protection. This was discussed with the manager who reported that she would store them appropriately in future. The inspector tracked two accidents reports that had been reported to the CSCI via Regulation 37 notifications. The accident form had been completed fully and also reports of these accidents were in the daily records of those residents. The maintenance man identified that the air conditioning in the kitchen remains broken and the home awaits a part for repair. This unit has been out of order of some time and was mentioned in the report of June 06. Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 33 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 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 1 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 34 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 OP2 Regulation 5 (1) Requirement The registered person must provide to all service users a contract of terms and conditions of residency, which should be signed by them or their representative. The registered person must ensure that the dignity and respect of service users is maintained at all times and that commodes are not left for storage in eating/communal areas The registered person must ensure that all incidences/allegations of abuse are reported without delay to the appropriate social services department as per inter agency policy and procedures. The registered person must ensure that all bedrails that are in use on residents’ beds are be covered with a protective bumper to prevent the risk of entrapment. The registered person must ensure that all parts of the home are in a good state of repair and DS0000012228.V341242.R01.S.doc Timescale for action 30/09/07 2. OP10 12 15/07/07 3. OP18 12 31/08/07 4. OP18 12 31/08/07 5. OP19 23 31/12/07 Marlborough House Nursing Home Version 5.2 Page 35 6. OP26 16, 23 7. OP33 24 8. OP33 12 9. OP36 18 that a programme of renewal of the fabric and decoration of the premises is implemented. The registered person must ensure that all parts of the home are clean and hygienic and that the home is free from offensive odours. The registered person must establish a system for seeking the views of service users and other stakeholders to enable them to identify levels of satisfaction and areas for improvement. This will allow the home to measure their success against the aims and objectives and Statement of Purpose of the home. The registered person must establish a system to quality audit records, maintenance of the building and the cleanliness of the home. The registered person must ensure that systems are in place for staff to receive supervision at least six times a year and records be maintained of these meetings. 31/08/07 31/10/07 30/09/07 30/09/07 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. Refer to Standard OP15 OP28 Good Practice Recommendations The service users should be consulted on the planned menus and what their preferred alternatives could be. The manager should be aiming to recruit staff that have the NVQ level 2 qualifications or encourage her existing staff to undertake this qualification to enable the home to meet the required national minimum standard. DS0000012228.V341242.R01.S.doc Version 5.2 Page 36 Marlborough House Nursing Home 3. 4. OP30 OP33 A training matrix should be developed by the deputy manager to enable him to identify the training that has taken place and by whom. The manager should review the Statement of Purpose to reflect the change of policy to a ‘No Smoking’ home Marlborough House Nursing Home DS0000012228.V341242.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 House Nursing Home DS0000012228.V341242.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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