Inspection on 22/06/06 for Marlborough House Nursing Home

This inspection was carried out on 22nd June 2006.

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

Other inspections for this house

Marlborough House Nursing Home 12/07/07

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 Val Sevier Unannounced Inspection 22nd June 2006 10:00 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.V295954.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.V295954.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.V295954.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 13th February 2006 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 it’s amenities. The establishment is comprised 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 buildings 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 provide access to the first floors of each of the respective parts of the home. The fees at the home range between £540 £710. Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 5.5 hours. The deputy matron and the staff on duty assisted throughout. All staff were helpful and positive about the home and the service they offered. The inspector was able to speak with several residents at the home about their experiences and three visitors. All the standards considered to be key to a service, were seen on this occasion. The inspector also followed through on requirements made following the last visit to the home. What the service does well: What has improved since the last inspection? The home was seen to have carried out all the requirements from the inspection in February 2006 with the exception of the fire equipment (please see below). These requirements were around: * Pre admission assessments; * Care plans; * Training for staff. The care plans seen offered full information enabling someone to care for the individual concerned. The pre admission assessment has also improved offering information related to the standards, which in turn inform the care planning process. Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 6 There were good systems and procedures in place to ensure that medication was managed safely in the home, residents’ financial affairs were safeguarded and that as far as possible residents’ were able to exercise self-determination and their civic rights. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Marlborough House Nursing Home DS0000012228.V295954.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 House Nursing Home DS0000012228.V295954.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home has an understanding of residents needs using the assessment process. The home has contracts with residents regarding the service offered. EVIDENCE: The inspector looked at 4 care plans and each individual had had an assessment prior to moving to the home. The assessments contain information about the needs of the individuals. It was observed that the information gained through the assessment had been used to complete the care plans. A relative spoken with on the day, explained what had happened in the decision-making process regarding the home and how he had been involved. The residents spoken with although able to speak for themselves had been unable to visit the home due to physical frailty. The relatives spoken with felt that the admission process had worked, that they had been given adequate information to assist with the decision, making process. The relatives felt that the needs could be met. Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 9 The inspector saw that contracts had been issued for the four residents that were being ‘tracked’ and signed by either the resident or their representative. Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 10 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, 8, 9, 10 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. There were plans of care in place that ensured that residents received the basic help and support that they needed. The home’s procedures and systems for ensuring that medicines were managed and administered safely were satisfactory. EVIDENCE: 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 home’s deputy and nursing staff said that relatives were asked to be involved in giving life histories and verbal input into the care to be provided. The response to this is very individual. Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 11 There was evidence that the home had looked at the suggestions from the previous inspection in February 2006, that care plans should include detail of some personal care and health needs relating directly to the areas covered in assessment, and had addressed this in the care plans seen. 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 person required. Observation and discussion with residents confirmed that individuals received the help they required in a timely way and that the equipment was in place as set out in their plans of care. There was documentary evidence that care plans were evaluated and reviewed regularly. Daily records were available for the 4 individuals whose planes were seen. It was noted that there was not always a record of action taken, for example a specimen was requested on four occasions over a week for an individual where there was concerns about their health. An entry a week later stated that a GP had been to the home and had prescribed medication on the basis of a test result. It was not clear when a sample had been obtained and could have been missed. This was discussed with the deputy at the inspection. 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. Comments from residents about the help that they received included the following: “They help me with everything I ask for even taking me to the toilet”. “The people look after me very well”. “The staff are lovely I have no complaints” The home had written policies and procedures available that were concerned with the management and administration of medication. The home is currently in the process of changing both the chemist they use and the way the system they use to store medication and administer medication. As a result there have been some difficulties on the continued supply of some medication. The registered nurse on duty told the inspector that she was aware of all medications that were due to re stocked during the transition and suitable arrangements had been made to cover this period. Medicines were stored safely and appropriately in, three locked and secure medicine trolleys and also in a locked room where dressings were also kept in locked cupboards. 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. Medicines were dispensed from their original containers and all of these were dated when they were opened/started. There were copies of the signatures of the nurses who dispensed medication readily available. Reference material and information about medicines was also readily available. 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 Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 12 sedatives the home managed as if they were controlled drugs. A check of these was made and the balance of medication held was correct. Good practice noted during the previous inspection in the areas of: checks of the effectiveness of the medical refrigerator (see above); dating of medication containers when they were opened; and promotion the right of residents to manage their own medicines if they wished subject to a risk assessment - continued. Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 13 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, 13, 14, 15 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home had good procedures in place for ensuring residents could exercise self-determination. The meals in the home were good and provided variety, choice and catered for special dietary needs. EVIDENCE: It was noted that on 2 of the care plans seen information had been supplied by the family where the resident was not able to communicate all needs and wishes. The staff said that they found this invaluable in planning care for those who are unable to communicate. The inspection had been used to plan the care of the individuals particularly in the area of social activities. Where an individual was frail and spent most of their time in their room the activities were taken to them on a one:one basis. The home was displaying details in the entrance hall of an organisation that could provide independent advice should a resident or relative want to obtain such help about matters that may cause them concern. There was evidence that residents furnished their own bedroom accommodation if they wanted to do so and several residents spoken to said Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 14 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. All residents spoken with said that the food provided by the home was good. 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 cook. All commented that if they did not like the meal that was on the menu there were other options. • “They will always change it if you are not keen”. They also confirmed that there three meals a day and could have snacks and drinks at other times. • “We always have a drink in the evenings and I have a biscuit with mine” • “I have a sandwich in the evening, cheese or ham”. • “There is always plenty of coffee all day”. • “We have our tea at about 5 to 5:50 and you can have something later if you want”. Information about the needs of service users with specific dietary requirements was readily available in the kitchen e.g. diabetic, soft, chopped up, etc. Pureed meals were provided with all their constituents prepared separately ensuring that their appearance was attractive. The cook stated that she had new menu planning ideas from a local supplier and was looking to incorporate some of these ideas into the menus at the home. Some service users ate 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. Comments from residents about the food included the following: • “The food is very good”. • “The food is very good, very filling…” • “It’s very nice….”. 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.V295954.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The manager has established a sense of openness at the home so that relatives and residents can voice their concerns. EVIDENCE: There have been no complaints made since the last inspection to either the home or to the CSCI. Relatives and residents spoken with were aware of how to complain and said they felt comfortable in speaking with the manager or deputy about any issues. The deputy and staff were able to explain the homes procedure when receiving a complaint and the action that they would take. There have been no allegations regarding adult protection at the home. The manager undertakes training the staff in this area, and staff spoken with were aware of the whistle blowing policy and the training. Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 Quality in this outcome area is poor. This judgment has been made using available evidence including a visit to this service. The home’s bedroom accommodation was furnished and equipped satisfactorily for residents needs. There were adequate systems and procedures in place to ensure the bedroom accommodation was both safe and comfortable however, communal areas of the home do not offer adequate protection for residents. EVIDENCE: A tour of the home was undertaken and it was seen that generally the accommodation was clean and tidy. There were areas where the paintwork was looking tired and chipped. An electrical socket in the lounge downstairs was not covered. The air conditioning unit in the kitchen was not working, several windows from the outside appeared to be damaged through rotting. One area of the home downstairs had a very strong odour which when discussed with the deputy manager the inspector was told that despite deep cleaning this carpet was known to smell of urine. Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 17 Of most concern was the garden where a hole has been dug for a pond, this could prove hazardous to residents who use the garden area and steps must be taken to risk assess and lessen the risk for residents. The laundry person was not available although the inspector saw the 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. All residents spoken with were satisfied with the standard of their bedroom accommodation and the furnishings and any equipment in the rooms. The furnishings of the rooms and décor were mostly in good repair. All bedrooms were; fitted with carpets and they were naturally ventilated and heated by radiators. A programme of installing guards on radiators in the “old/original” part of the home had been implemented and to prevent residents from the risk of suffering burns. The radiators in the extension or new part of the building were appropriately guarded. This included both communal areas and bedrooms. In residents rooms where a guard had not been fitted a risk assessment had been done to ensure that action was taken to minimise the risk to the individual concerned from the uncovered radiator. It was noted at the inspection in February 2006 that the home was experiencing problems with the boiler and temperature of hot water tested in the wash hand-basin in a ground floor room in the old part of the house greatly exceeded 43°C which is considered the maximum appropriate and safe level in care homes. The water in the upstairs bathroom and toilet continue to exceed this ‘safe’ temperature’. The maintenance person for the home confirmed that water outlets on baths in the home were fitted with thermostatic mixer valves, to ensure that the temperature of the hot water was delivered at a safe temperature and the outlets were checked regularly. However there would appear that there is still an issue at the home. It was noted that there is a book in which staff write items that need attention such as light bulbs needing to be changed and radiators that continued to be hot even though the system had been changed to suit the warmer weather. The staff and residents said that issues were followed up. Some comments that residents made about their bedroom accommodation and the communal areas of the home were: • “I think I have a nice room”. • “My bed is quite comfortable”. • “I like the lounge it is bright”. Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home provides adequate staffing and assists staff with a good training programme in order to meet resident’s needs. The home’s recruitment procedures for new staff were adequate in the protection vulnerable adults living in the home. EVIDENCE: The rota was seen for the home and there appeared to be adequate staffing for the needs of the residents. There are two nurses on during the day supported by care staff and one nurse at night also supported by care staff. In addition there are kitchen staff, a laundress, housekeeping staff and an activities person. The pre inspection questionnaire returned by the home indicated that training was planned for the year for staff. This was seen at the inspection and staff confirmed that they had been asked what training they would like in addition to the mandatory training. A registered nurse who has also completed training in adult education will coordinate or give the training at the home. The inspector spoke to some staff that commented that they liked the weekly sessions, which are held as they feel more informed about residents needs and they are able to discuss difficulties. A training programme for the year was seen to include mandatory training in food hygiene, fire and moving and handling. The home has plans to carry out training in areas of dementia as required from the last two inspections. Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 19 The inspector sampled four staff files for those that had begun employment at the home since the last inspection in February 2006, when there had been concerns about the process regarding staff recruitment. It was seen that the home had improved its recruitment procedure with checks carried out on staff before employment commenced, protecting residents. Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is adequate. This judgment 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, health and safety records for fire are not comprehensive and must be in place. EVIDENCE: The registered manager was on annual leave on the day of the inspection; however there has been no change to the comments made following the previous inspection to the home in February 2006. Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 21 In the main views from both residents and staff concerning the management of the home were positive for example: • “She is very supportive… (staff member). • “Matron is lovely” (resident). • “She is very nice” (resident) Comments from residents were also made about the staff generally, having no concerns and relatives knew that if the matron/manager was away then the nursing staff or deputy would help them. There was evidence that the manager had begun to audit areas of services provided at the home, ensuring that care plans were reviewed regularly for example. Regular meetings are held in the home for different groups of staff according to their roles e.g. catering, registered nurses, as well as the whole staff team. The deputy said that although they continue to offer meetings with relatives mostly the conversations are held on an individual basis when the relatives feel there is a need. Relatives spoken with confirmed that they feel supported by staff when they have questions or are worried. There had been 4 requirements and 3 recommendation made as a result of the last inspection of the home on February 2006 and most had either been actioned fully or progress was being made with them. One matter has not been addressed that being the recording of checks made on a weekly basis of the fire alarm system. There was evidence that monthly checks have taken place and that the system has been serviced as needed, however although the staff stated that there are tests each Monday of the fire alarms there are no records to confirm this. The registered persons are required to ensure that records are kept to evidence that the alarm system is checked on a regular basis. The home looks after money on behalf of some residents for security purposes Records were kept of any expenditure or deposits of additional monies (i.e. incomings and outgoings). A sample of the records of 2 residents who had money being looked after by the home were examined and checked against the balances being held and they were accurate and up to date. There was evidence from both discussions 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. Fire training was seen to be undertaken on a monthly basis, this was a requirement from the last inspection in February 2006. There are two Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 22 members of staff who undertake the training at the home, both of whom have been to training at Hampshire Headquarters. There were records of which staff had undertaken training, and the trainer stated that having sessions each month meant that training was ongoing and that they covered all staff in this way. Records also indicated that the safety of the home’s environment was audited regularly and that most systems and equipment in the home were tested and serviced at intervals and with the frequencies either required according to relevant regulations or good practice and that contracts were in place for essential services. These included: • Fire safety equipment • Boilers and central heating • Hoists and slings • Lifts • Pest control • Portable electrical appliances • Refrigerators and freezers A food safety report of an inspection by the local environmental health officer in March 2006 was seen in which it stated that several pieces of equipment needed to be cleaned and that the kitchen staff need to update their training in food hygiene, these have been actioned. However it was noted that on the day of this inspection the day was very warm and that the air conditioning unit in the kitchen was not working this must be addressed. Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 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 1 2 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 3 X X 1 Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 23 (2) Requirement The registered person must ensure that safety in the home is maintained with electrical sockets being covered. The registered person must ensure that the garden is safe for residents use under a risk assessment framework. The registered person must ensure that hot water at point of delivery is at a maximum of 43 degrees C. The registered person must ensure that the home is kept clean and free from offensive odours. The registered persons must ensure that the all fire systems and equipment in the home that are inspected and tested at the frequency set out in the relevant heath and safety legislation and/or guidelines, have full records maintained. (This is an amended requirement from 31/05/06) Timescale for action 31/07/06 2 OP19 23(2)(o) 31/07/06 3 OP25 23(2) 31/07/06 4 OP26 16 (2) (k) 31/07/06 5 OP38 23(2) (c) 31/07/06 Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 25 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 OP38 Good Practice Recommendations It is recommended that the fire escapes are cleaned regularly to help prevent mould growth and to promote safety in the event of them being used. Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Marlborough House Nursing Home DS0000012228.V295954.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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