Inspection on 15/02/06 for The Marguerite Centre

This inspection was carried out on 15th February 2006.

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

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

Other inspections for this house

The Marguerite Centre 12/03/08

The Marguerite Centre 27/09/06

The Marguerite Centre 11/04/05

The Marguerite Centre 20/12/04

The Marguerite Centre 05/04/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE The Marguerite Centre The Royal Bucks Hospital Buckingham Road Aylesbury Buckinghamshire HP19 9AB Lead Inspector Christine Sidwell Unannounced Inspection 15th February 2006 09:30 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 The Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Marguerite Centre Address The Royal Bucks Hospital Buckingham Road Aylesbury Buckinghamshire HP19 9AB 01296 678800 01296 678800 jan@royalbucks.co.uk www.rehab@royalbucks.co.uk Mr J Clarke 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) Janet Sillitoe Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (5) of places The Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the home provides care for Physically Disabled service users over 45 years of age. That the home provides Respite Care. That the home provides Intermediate Care. Date of last inspection 11th April 2005 Brief Description of the Service: The Marguerite Centre is care home with nursing, situated within the Royal Buckinghamshire Hospital. The hospital is close to Aylesbury town centre offering level access to restaurants, a library, a shopping centre, cinema and other local amenities. The Marguerite Centre offers long-term nursing and respite care to people over the age of forty-five, including married couples. There has been a recent change in registration to allow the home to offer intermediate care for up to eight people. The home is on the first floor of the Royal Buckinghamshire Hospital and is on one level, making it wheelchair accessible. Access to the home is via a service lift. There is always a registered nurse on duty supported by healthcare assistants. The Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection undertaken on the 15th February 2006. The purpose of the inspection was to assess the key standards, which were not assessed at the inspection undertaken on the 11th April 2005, and to follow up on any requirements made at that inspection. Residents, staff and visitors were spoken to and some records were examined. A follow up visit was undertaken on the 2nd March 2006 when the Chief Executive of The Royal Buckinghamshire Hospital and the home manager were seen. What the service does well: What has improved since the last inspection? What they could do better: The care plans provide the basic information required by carers to meet resident’s needs. Some residents however would benefit from a comprehensive falls assessment and plan of care to minimise the risk of falls. A full social history should be undertaken to ensure that residents are able to continue with their previous hobbies and diversions where they are able. The recruitment processes should be improved to ensure that all staff have two references and a Criminal Records Bureau disclosure before commencing work. The recruitment files should also contain an up to date photograph of the staff member. The home manager, with the new management team of The Royal Buckinghamshire Hospital, should review the quality assurance programme to ensure that it is comprehensive and includes seeking the views of residents, The Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 6 their families, staff and other stakeholders on the quality of care offered at the home on a regular basis. 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 Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 7 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 The Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 8 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): none These standards were not assessed at this inspection. They were met at the inspection undertaken on the 11th April 2005. EVIDENCE: The Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 9 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 The care plans provide the basic information required by carers to meet resident’s needs. Some residents would benefit from a comprehensive falls assessment and plan of care to minimise the risk of falls. A full social history should be undertaken to ensure that residents are able to continue with their previous hobbies and diversions, where they are able. EVIDENCE: The care plans of five residents were examined. All had good assessments and care plans to meet daily needs. All had had Waterlow, manual handling and nutritional risk assessments. One resident had had two falls and this was noted in the incident book, although she did not have a falls assessment in her care plan. It is recommended that all residents have falls assessments in line with protocols developed by the local Primary Care Trust. One resident was on respite care. These beds are spot purchased by the local social services team. The resident had not had a pre-assessment to establish whether the home could meet her needs, although she had had a comprehensive assessment on arrival at the home. The daily entries to the care plans had been signed and dated. Some of the language could be improved, for instance ‘bed rails’ should The Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 10 replace the words ‘cot sides’. Not all care plans had a life history or details of resident’s social likes and dislikes. This should be addressed. The Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 11 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 Efforts are made to provide residents with activities and diversion during the day although these may be more relevant to individuals if their interests were recorded and individual programmes developed to meet them. EVIDENCE: The residents spoken to said that the routines of the home were flexible. There is an activities coordinator who visits the home regularly and arranges small group activities. There was evidence that a variety of activities and entertainments had been provided over the Christmas period. Individual resident’s activity likes and dislikes are not always recorded in the care plans and the focus is on small group activities. The home should consider identifying and recording individual preferences and developing some individual programmes to meet these. The Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 12 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): These standards were not assessed at this inspection. They were met at the inspection undertaken on the 11th April 2005. EVIDENCE: The Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 13 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): These standards were not assessed at this inspection. They were met at the inspection undertaken on the 11th April 2005. EVIDENCE: The Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 14 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): 28 and 29 The home’s commitment to training care staff to meet the resident’s needs is to be commended. The recruitment procedures should be improved to ensure that residents are protected from potentially unsuitable staff. EVIDENCE: In addition to the qualified nursing staff, there are eleven permanent healthcare assistants and three bank healthcare assistants, who work flexibly. Five hold the National Vocational Qualification (NVQ) in Care at Level 3 and three hold it at Level 2. A further three are undertaking the course leading to Level 2. The home meets the standard that 50 of care staff hold this qualification. There are no trainees under 18. The recruitment files of three new members of staff were examined. Two had the required documentation although did not have up to date photographs of the staff member. One member of staff had commenced work before the Criminal Records Bureau disclosure had been received. There was no POVA first email on file. He also only had one reference. The home should ensure that the necessary pre-employment checks are undertaken prior to new members of staff commencing work. It is also recommended that the home undertake a thorough audit of recruitment files to ensure that all the required documentation is on file. The Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The home is well managed providing residents with a happy environment in which to live. The quality assurance programmes should be reviewed and the views of residents, their families, staff and other stakeholders should be sought on a regular basis. The health and safety systems have improved since the last inspection protecting residents and staff from adverse events. EVIDENCE: The manager has had at least two years experience of managing a care home and holds the National Vocational Qualifications in Management at Level 4. She is a Registered Nurse. She is responsible for one care home although participates in the general management of the Royal Buckinghamshire Rehabilitation Hospital. The staff spoken to said that they had had confidence in her and felt able to report any concerns that they had to her. She is experienced in caring for the elderly and those with physical disabilities. The Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 16 The Royal Buckinghamshire hospital has an audit programme in place although the manager said that she was not currently involved in this. The Chief executive has sent the reports of his quality assurance visits to the Commission for Social Care Inspection although this is not yet reliable and neither are he reports comprehensive. A survey of view of residents, their families and other stakeholders has not been implemented in the last year. The quality assurance programme should be reviewed to ensure that it is comprehensive and includes systematic approaches to seeking the views of residents, their families and other stakeholders. Resident’s financial affairs are managed by their families. Where residents choose to leave a small amount of money with the home, for expenditure such as hairdressing, this is banked in a treasurer’s account and records are kept detailing expenditure made on behalf of residents. At the last inspection a requirement was made that more staff hold up to date first aid qualifications in order that a qualified first aider is on duty at all times. There are now four qualified first aiders on the staff of the Royal Buckinghamshire Hospital in addition to the qualified nursing staff and the resident doctor on call. A requirement was also made that the home’s satellite kitchen temperatures were monitored carefully and accurately. This has now been complied with. The Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 17 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x x x STAFFING Standard No Score 27 x 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 The Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 18 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 OP7 Regulation 15 Requirement The care plans should be developed to include a full social history and records of resident’s activity likes and dislikes. All residents should have a fall assessment in line with guidance from the local Primary Care Trust. All recruitment files must contain the information specified in Regulation 19 schedules 2 and 4 of the Care Homes Regulations 2001 The home manager with the new management team of The Royal Buckinghamshire Hospital should review the quality assurance programme to ensure that it is comprehensive and includes seeking the views of residents, their families, staff and other stakeholders on the quality of care offered at the home on a regular basis. Timescale for action 30/06/06 2 OP7 12 30/04/06 3 OP29 19 30/04/06 4 OP33 24 30/06/06 The Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP29 Good Practice Recommendations It is recommended that a full audit of the recruitment files be undertaken to ensure that they contain the required documentation. The Marguerite Centre DS0000019241.V283503.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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. 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