Care Home: Marlborough Court Care Centre

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What the care home does well Information for new residents is in place and the standardised forms for care planning are satisfactory. The environment is very good with few faults. There is a new management team and they seem to be building a competent workforce producing some excellent feedback from residents, in summary they staff are excellent. Overall this home is improving and achieves good outcomes for residents. What has improved since the last inspection? Requirements and recommendation have been addressed and the home has cooperated with the local authority when they have dealt with safeguarding referrals. There is a new manager in post. New housekeeping and cleaning arrangements in progress. What the care home could do better: A number of points were identified for attention by the manager including some areas of the environment needing improvement; doctors’ note need to be held more securely and staff written records about doctors’ visits need to be clearer in residents’ files. It is disappointing, given the home’s riparian location, that easier access is not available to the banks of the Thames. The home’s sensory garden also needs improving. Key inspection report CARE HOMES FOR OLDER PEOPLE Marlborough Court Care Centre 7 Copperfield Rd Thamesmead London SE28 8RB Lead Inspector Michael Williams Key Unannounced Inspection 29th May 2009 09:00 DS0000006766.V375626.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marlborough Court Care Centre Address 7 Copperfield Rd Thamesmead London SE28 8RB Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8310 8881 020 8310 7767 marlboroughcourt@schealthcare.co.uk Exceler Healthcare Services Leasing Limited Care Home 78 Category(ies) of Dementia (28), Old age, not falling within any registration, with number other category (50) of places Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing (CRH - N) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places: 50) 2. Dementia - Code DE (maximum number of places: 28) The maximum number of service users who can be accommodated is: 78 30th May 2008 Date of last inspection Brief Description of the Service: Marlborough Court Care Centre is a purpose built, three-storey home situated in North Thamesmead overlooking the River Thames. The home consists of 21 single bedrooms on the ground floor for people requiring conventional nursing care, 27 single bedrooms for older people with dementia on the first floor and 29 single bedrooms for older people requiring conventional personal residential care on the second floor. All of the rooms have en-suite facilities. Each unit has a separate dining room, two lounges, toilets and three bathrooms. A separate laundry, kitchen and staff changing facilities are provided on site. Outdoor areas include a garden, patio area and an aviary at the front of the property. Visitors can park in the private car park in front of the home. Fees in May 2009 were £450 to £800. Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. On 29th May 2009 we made a site visit to the home. We met with residents, staff visitors and the home’s manager and area managers. We toured the building to check for safety and comfort. We also checked a wide range of documents including staff files, care plans, record keeping and so forth. We also took account of surveys and other information the Commission received. What the service does well: Information for new residents is in place and the standardised forms for care planning are satisfactory. The environment is very good with few faults. There is a new management team and they seem to be building a competent workforce producing some excellent feedback from residents, in summary they staff are excellent. Overall this home is improving and achieves good outcomes for residents. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 Page 6 You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 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 Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 3: People using the service good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents are provided with suitable information including information about how their needs can be met so they can make a choice about whether to live in this care home. EVIDENCE: We checked a number of residents’ case files and spoke to residents and their visitors. We spoke to staff and the manager about the arrangements for admission. The documentation support admission is very detailed and thorough. Assessments are in place for residents so they know that their needs have been carefully identified and can be met by the home. The home itself tells us in their annual audit (AQAA) ‘All service users have pre admission assessments on file, including information from other professionals. All service users have a signed contract on file. All service have an up to date Service User Guide. Marlborough Court has an ongoing training programme to ensure all staff are able to meet the needs of all service users’. Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7 to 10: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Health and social care is well planned and managed so that residents’ needs are being met. EVIDENCE: As with the previous section we checked a range of documents including case files, medication records, we spoke to a number of residents and to their visitors and we spoke to the management team. The document is well maintained but we did note that nurses were not keeping a clear enough record of medical visits. This is a large home with mixed conditions of residents so that the home can provide for older people with dementia and those who do not have this condition. The home must keep each resident’s condition under review so as to ensure they are being cared for in the most appropriate section of the home. Not all residents had their life history reflect in their personal file and care plan. We were told in the numerous survey forms we received that this home ‘does very well for the personal wellbeing of residents’. A first time visitor told us ‘everything seems very good’. Others also told us that the home provides ‘really good care and support’ and describes staff as excellent. The Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 Page 10 home’s statements about health care are. ‘All clients have an individual care plan. Care plans are all person centred and holistic. Care plans are comprehensive and detailed. The assessment tool is being reviewed by head office care planning committee to assess its usefulness especially with regard to skill mix and staffing levels. Further guidance has been giving to staff to ensure that they are using it correctly whilst awaiting the outcome of the review. All staff have had further training in completion care planning documentation. Body mapping and weights are being assessed weekly. Wound management documentation has improved substantially. Accident forms completed and statements being taken from all staff concerned. All medications are documented and stored accorded to guidelines and company’s policies and procedure. All homely are ordered, stored and administered as per the company’s policies and procedures. Residents who lack capacity have protocols in place for their as required medications. Staff responsible for administration of medications have an annual competency assessment. All clients are treated with respect and dignity, ensuring privacy is upheld. Personal hygiene needs are being addressed via person centred, holistic care planning. More attention is being paid to personal grooming by the staff. Call bells are answered promptly and staff are being more proactive with regard to meeting service user needs. Service users and relatives are treated with sensitivity and respect at time of death. All clients have the right for choice’. Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12 to 15: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Social life for residents is well managed so that residents can expect as full and fulfilling lifestyle as they can wish and manage. EVIDENCE: The home employs an activity lady but staff also assist in the activities programme. In our surveys we were told some residents prefer to stay in bed and t was suggested that more support might be given to residents who isolate themselves in this way. We are told this home has a nice atmosphere and staff are always very friendly. One person told us she liked the ‘tuck-shop’ and the entertainment. We are also told that food is very good here. We commend that activity person for joining the national association of activity providers [NAPA] and we have doubt she will pick up many good ideas through this group. The meals are very good and visitors are always offered a cup of tea we understand. We make two recommendations in this section. We thought that instead of fixed and rather rigid ‘menu’ of activities for each week a more open list of options might give more choice and reflect the way the day is unfolding, the weather, staffing levels, staff skills, transport availability and so forth. The activity coordinator agreed to explore this approach to providing activities for all residents. We also note that personal preferences for activities and interests are not always outlined in care plans. Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 Page 12 Of social life in the home, we are told by the home in their audit tool that the home ‘Provides activities that meet the needs of the service users, by providing activities requested by service users. Monthly newsletter. Outings for residents. Activity organiser and care staff keep more accurate records. Take residents out shopping. Residents with capacity enjoy independent outings to the shops. External trainers. Individual celebration days for resident’s birthdays and other celebrations. Mobile library comes every week. Encourage friends / families to visit the home at any time. Provide a friendly caring environment that ensures service users and families feel welcome. Encourage service users to make choices and to promote independence. Provide wholesome appetising meals to meet the needs of all service users. Encourage relatives to dine with their loved ones by providing the opportunity to book in for Sunday lunch at a minimal charge’. Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 16 and 18: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for dealing with complaint and for safeguarding residents are in place so they can feel listened to and protected. EVIDENCE: The complaints procedure is on display in various locations and these documents provide adequate information about what people should do if they wanted to make a complaint. Information is provided about the Commission as required. There were timescales for staff to follow when investigating concerns. Guidance was provided about the different stages that people could follow if they were not satisfied with the response provided by the home. A policy and procedure was in place in relation to safeguarding adults. Staff we spoke to had a good understanding of their role in safeguarding adults and understood the ‘whistle blowing’ policy. Several safeguarding adults referrals have been investigated by the local authority (LB Bexley) Safeguarding Adults Team. However, it was evident in our last inspection in 2008 that the Commission was not being made aware of these critical incidents. This was a matter of concern as the home had a responsibility to report all significant incidents/accidents within the home to the Commission (as well as to the local authority where the home is based is based and to the placing authority if different). The Operations Manager acknowledged the shortfalls at that time and undertook to produce new guidance and a tracking system to ensure these lapses did not continue. So we now note that notifications are being sent when necessary. Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 Page 14 The home says of this section, ‘Residents and their families are encouraged to raise any concerns immediately with the staff on duty. The launch of the Action on Elder Abuse Helpline. Complaints procedure displayed in reception. All complaints are documented and recorded. Investigations are carried for each complaint and a response is sent within the time scale. Service users legal rights protected as in policies and procedures. Service users are protected from abuse by ensuring staff are trained in adult protection and safeguarding, and all staff receive a CRB / POVA check prior to employment. Regulation 37 notifications are sent to CSCI and placing authorities without delay’. Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 19 and 26: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although not without some minor shortcoming the home is safe and well maintained so that residents can live a comfortable and protective environment. EVIDENCE: This home is generally clean, tidy and well maintained, there is an odour free atmosphere and the appointment of housekeeping is commended and she has re-organised the cleaning roster and schedules to ensure cleaning is maintained throughout the week. A number of minor pieces of damage to the fabric of the building need attention such as hole in wall of clinic room; light bulbs not working; laminate peeling off kitchen units; taps dripping and leaving unsightly stains in sinks/baths. With an area manager present we note that the hot water dispensers in the kitchenettes was very hot indeed (to make tea on each floor) and we agreed Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 Page 16 they were not vital pieces of equipment to have on each floor so they will be removed and tea arranged direct from main kitchen. An ordinary domestic kettle may also be safer in some areas. One resident told us that others are apt to wander into her room and take or damage things in her room; this suggests the need for better supervision of residents throughout the day. We note that the home as an outside area sign-posted the sensory garden. It is now somewhat neglected and shows little evidence of enhancing sensory experiences for residents visiting the patio. It needs overhauling; the roses for example are now overgrown and beyond anyone’s height to smell and observe, staff had no idea where the switch was to turn a small wall-mounted water feature – they were in fact unaware of its existence. Residents say they would like to see more flowers in this area and we agree that would be a great benefit to residents. The area also needs regular maintenance. The home’s position in respect of the general environment is as follows. ‘The home conducts weekly / monthly audits on all equipment. Various risk assessments are completed for equipment as well as areas within the home. Service users have free access to all communal facilities both indoor and outdoor. The home have a variety of communal bathrooms and all rooms have en suite toilet. The home has a variety of equipment available to meet the service users needs. This audited to ensure adequate equipment is available to staff. There is an efficient computerised ordering system in place with a prompt delivery service. All service able to choose their room from those available at the time of pre assessment and or admission. Service users are encouraged to bring in personal items to give their room a more personal touch. Service users rooms and communal areas all risk assessed. Despite certain areas needing updating, the home is clean and tidy and has an odour free environment. Staff are very committed to ensuring all service users are cared for in a clean, safe and odour free environment. Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 27 to 30: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. With the appointment of a new manager the service is now providing good outcomes for residents in respect of staffing. So we are advised that staffing now meets residents needs more fully than in previous inspection. EVIDENCE: Last year the Commission required the service to review staffing levels and the deployment of Nurses. This year we understand that staffing level are better are now more fully meeting residents needs including health care needs. This is reflected in the many replies we got to our written surveys. Many respondents complimented the staff team and described them for example, as ‘very helpful’, very caring, ‘staff ask if there is any more they can do (for the resident)’, and described the care a ‘really good. Staff are described as ‘polite and willing to listen’. One person told us they appreciated the work of people working behind the scenes, cleaners, domestic and kitchen staff for example, this person clearly appreciated the ‘team work’ of the whole staff team. Could that We checked a number of records including staff training and supervision records. We did not check staff recruitment records because they are held at head office – they can be made available to the Commission when we request to see them. We did note that some staff have strong accents and may need help with their spoken English. We are advised in the home’s own assessment of staffing matters that they ‘Provide an established staff Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 Page 18 compliment. Provides staff with various skills mix to meet the needs of the service users. Supernumerary hours are provided for the deputy manager and senior nurse. Service users safety and well being is paramount with all employees. Employees will be required to provide a previous work history, 2 references (1 from most recent employer), CRB POVA checks. All employees follow an induction programme followed by alternate month supervisions. Once completed staff are required to enhance and maintain their skills by continued training. Provide staff that in the main have worked at Marlborough Court for many years, therefore provide service users with continuity. Provide numerous training courses to all staff, reflective of the service users needs. Dementia training is on going’. And for the future the home tells us that it aims to ‘Recruit more bank staff, to employ an ‘in house trainer’ and for Manager and senior staff to complete training on the Mental Capacity Act, thereafter be competent to address the care planning of wishes of the client / families at the event of death. Fnally they tell us that they will continue with the development the skills of all staff. Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 31, 33, 37 and 38: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. On this occasion we find Marlborough Court to be well managed so that residents can be confident the home is being run in their best interests. EVIDENCE: One person responding to our surveys wanted to compliment the people working ‘behind the scenes’ and included the deputy and new manager’ as praiseworthy. This reflects the improvements made since our last visit in 2008. Marlborough had been without a Registered Manager for three years following a succession of nine managers and acting managers. It is understood that the permanent managers had either resigned or been dismissed, prior to any application being made to apply to become the Registered Manager for the Home with the Commission. This has resulted in ongoing instability for both Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 Page 20 residents and staff members alike and it is very important that this continued disruption and lack of continuity of managers be brought to an end. The present incumbent has given assurances that she intends to stay and sustain the improvements made in recent months. There was evidence from previous inspections that the Operations Manager and the Homes manager complete routine and regular audits on the quality of the service. The audits were based on the national minimum standards and covered areas such as medicine management, complaints, the environment, pressure sore care and prevention, activities and health & safety. Visits were made to the home on behalf of the owners, these are known as ‘Regulation 26 visits and reports are held in the home and are to be made available to the Commission when we request to see them. Resident meetings were held periodically and the minutes show residents could have their say about issues that mattered to them such as the meals provided. Relative meetings were also held and this is commended. Topics that can be discussed at these meetings include the management of laundry, dementia care and end of life care. Meetings are also help with unit staff, heads of departments, specifically about health & safety matters. The homes own assessment of the management of this service is that ‘there is still no registered manager within the Home. The Acting Manager is very positive about the commitment of the staff to maintain the improvements already in place within the Home. The atmosphere is welcoming and the satff appear very positive and greet visitors in a very pleasant manner. Marlborough Court provides an established leadership and management structure. There is a long term administrator, established deputy manager, and senior staff structure. The Management and staff aim to ensure the home is run for the best interest of the service users. All insurance certificates are displayed in reception. All accounts are audited by accounting department. Any service users depositing money within the home have a dedicated bank account with interest payments being made direct to the service users. Staff regularly supervised. All record keeping maintained as in the homes policies and procedures. All contract (Safety and Maintenace) certificates up to date and well maintained’ and thenthe . Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 Page 21 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 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 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X 3 3 Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 Page 22 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 OP19 Regulation 23 Requirement Timescale for action 30/11/09 2 OP19 23 Maintenance: The home is required to improve maintenance of the home including lighting bulbs and light-shades and the level of lighting. This is so that residents have more comfortable lighting levels. Maintenance: The home is 30/11/09 required to improve maintenance of the home including plumbing, dripping taps and stained sinks/baths. 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 OP7 Good Practice Recommendations Social Care Planning: It is recommended that all care plans include an element of social care including personal references and activities of choice. This is so residents know they will e able to lead fulfilling lives in the home. DS0000006766.V375626.R01.S.doc Version 5.2 Page 23 Marlborough Court Care Centre 2 OP14 3 OP27 4 OP19 Social Activities: It is recommended that a wider range of activities is offered by dispensing with weekly ‘menu’ of daily events. This is so that residents have greater choice of activities each day. Staff skills: It is recommended that staff are given support and training in improving their English language skills. This is so as to improve communication between residents and staff. Gardens: It is recommended that the gardens are improved and consideration is given to better access to the Thames bank-side. Marlborough Court Care Centre DS0000006766.V375626.R01.S.doc Version 5.2 Page 24 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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