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Inspection on 19/03/08 for St Margaret`s Nursing Home

Also see our care home review for St Margaret`s Nursing Home for more information

This inspection was carried out on 19th March 2008.

CSCI found this care home to be providing an Good service.

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.

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

What the care home does well

Clear assessments are carried out to make sure that people moving into the home can have their needs met. Relatives said this home was chosen because it has such a friendly, homely atmosphere. Care plans are well completed and showed good nursing care. The home makes sure that nurses have the opportunity to maintain and develop their nursing skills and competencies. Good, varied outside entertainment and group activities are provided for the people living in the home. Residents said they enjoy the food and one person commented that "the meat is first class and there`s plenty of it." Attention is paid to a balanced healthy diet including fresh fruit and vegetables.Residents said that they are well looked after and that staff are kind and know their likes and dislikes. Residents said that they feel safe. Staff interacted with the residents and each other in a calm and cheerful manner. Staff said they enjoyed the training opportunities provided which include NVQ and palliative care. The home also acts as a base ward for 1st year student nurses from Christchurch College. Staff spoken to demonstrate that they are knowledgeable of the needs and conditions of the residents. The home has Investors in People status. The providers visit the home twice a week and write a weekly report. The home and gardens are well maintained and decorated. Residents` rooms are personalised with their own belongings. Systems are in place to provide a safe environment through risk assessments and regular audits.

What has improved since the last inspection?

Residents and their relatives are involved in parts of the compilation of the care plan and other parts are explained fully. All records and charts to maintain good nutrition, skin care and hydration are kept in the care plan. Specialist equipment has been purchased including high profile beds, airflow mattresses and digital hoist scales. New lounge and bedroom furniture has been purchased. Some parts of the home have been decorated and there is a new hall carpet. The manager has improved the organisation of staff files and they contain all necessary information.

What the care home could do better:

The owners have responded to the feedback they have received from people and what has been identified in previous inspections regarding the lack of communal space and storage space in the home. There are plans to increase the size of the home overall by building an extension. The laundry needs to be improved. It is really small and there is insufficient space to store the clothing and linen. Recently the washing and drying machines have not always been reliable. The manager has responded to individual complaints. It was agreed that a more immediate plan to extend the laundry room was needed and a review of the equipment. There were some comments about staff being busy and sometimes not answering the call buzzers very quickly. The manager said she would look at the way the staff team are organised and make sure enough staff are availableto respond in a timely way. This will be followed up through the homes quality monitoring system.

CARE HOMES FOR OLDER PEOPLE St Margaret`s Care Home (Nursing) 20 Twiss Avenue Hythe Kent CT21 5NU Lead Inspector Julie Sumner Unannounced Inspection 19th March 2008 10:30 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 St Margaret`s Care Home (Nursing) DS0000026119.V359461.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. St Margaret`s Care Home (Nursing) DS0000026119.V359461.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Margaret`s Care Home (Nursing) Address 20 Twiss Avenue Hythe Kent CT21 5NU 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) 01303 267557 F/P 01303 267557 www.stmargaretshythe.com Charmdale Healthcare Ltd Mr Jaspal Singh Chatwal Mrs Amanda Suzanne Atkins Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24), Physical disability (1) of places St Margaret`s Care Home (Nursing) DS0000026119.V359461.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service user under the age of 65 years old are restricted to 1 (one) whose DOB is 19/05/1946 Date of last inspection Brief Description of the Service: St Margarets Nursing Home is a detached two-storey building, which has been extended and converted to provide accommodation for 25 elderly residents requiring nursing care. It is situated on the outskirts of Hythe alongside the Royal Military Canal and Waitrose supermarket. The home has disabled access to the front door. There is a well maintained back garden and car parking spaces in front of the home. It is owned by Charmdale Healthcare Ltd and the Directors are Mr Baldeep Singh Chatwal and Mr Jaspal Singh Chatwal. The company owns the house next door, currently used as staff accommodation. The Company owns two other care homes in East Kent. Mrs Amanda Atkins is the manager registered with the CSCI. Accommodation comprises 21 single rooms, nine with en-suite facilities and 2 shared rooms. The home has one communal area used for both sitting and dining area. There is a lack of space in respect of visitors/interview room, small laundry and small manager’s office. Current weekly fees are in the range of £386.98 to £739.00 with additional charges for newspapers, hairdressing, chiropody and toiletries. The statement of purpose and service user guides are available from the home. The home has a website the address is: www.stmargaretshythe.com The e-mail address for the home is asastmargarets@aol.com. The inspection report is freely available to all who wish to read it. St Margaret`s Care Home (Nursing) DS0000026119.V359461.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. This report is based on information received about St. Margaret’s Nursing Home including an annual quality assurance assessment (AQAA) completed by the manager and an unannounced site visit to the home lasting around 7 hours. Information was gathered for this inspection in a variety of ways both prior to and during the visit to the home. Surveys have been sent out to residents, relatives, staff and visiting professionals. Those returned have been taken into account in this report. The visit included talking with residents, the manager, staff and some visiting relatives. General observations were made during the day of how people are supported. There was a tour of the building and various records were inspected. The people living in St. Margaret’s Nursing Home were able to participate in the inspection by having conversations about their lifestyle and completing the surveys prior to the visit. What the service does well: Clear assessments are carried out to make sure that people moving into the home can have their needs met. Relatives said this home was chosen because it has such a friendly, homely atmosphere. Care plans are well completed and showed good nursing care. The home makes sure that nurses have the opportunity to maintain and develop their nursing skills and competencies. Good, varied outside entertainment and group activities are provided for the people living in the home. Residents said they enjoy the food and one person commented that “the meat is first class and there’s plenty of it.” Attention is paid to a balanced healthy diet including fresh fruit and vegetables. St Margaret`s Care Home (Nursing) DS0000026119.V359461.R01.S.doc Version 5.2 Page 6 Residents said that they are well looked after and that staff are kind and know their likes and dislikes. Residents said that they feel safe. Staff interacted with the residents and each other in a calm and cheerful manner. Staff said they enjoyed the training opportunities provided which include NVQ and palliative care. The home also acts as a base ward for 1st year student nurses from Christchurch College. Staff spoken to demonstrate that they are knowledgeable of the needs and conditions of the residents. The home has Investors in People status. The providers visit the home twice a week and write a weekly report. The home and gardens are well maintained and decorated. Residents’ rooms are personalised with their own belongings. Systems are in place to provide a safe environment through risk assessments and regular audits. What has improved since the last inspection? What they could do better: The owners have responded to the feedback they have received from people and what has been identified in previous inspections regarding the lack of communal space and storage space in the home. There are plans to increase the size of the home overall by building an extension. The laundry needs to be improved. It is really small and there is insufficient space to store the clothing and linen. Recently the washing and drying machines have not always been reliable. The manager has responded to individual complaints. It was agreed that a more immediate plan to extend the laundry room was needed and a review of the equipment. There were some comments about staff being busy and sometimes not answering the call buzzers very quickly. The manager said she would look at the way the staff team are organised and make sure enough staff are available St Margaret`s Care Home (Nursing) DS0000026119.V359461.R01.S.doc Version 5.2 Page 7 to respond in a timely way. This will be followed up through the homes quality monitoring system. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Margaret`s Care Home (Nursing) DS0000026119.V359461.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Margaret`s Care Home (Nursing) DS0000026119.V359461.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been carried out. EVIDENCE: The assessment process was discussed with the manager. A sample of two admission assessments including joint assessments were briefly viewed. The pre-admission forms have been adapted in line with the Mental Capacity Act. The people living in the home said that they were given enough information to make a decision about moving in. A comment in a service user survey read: “I had all information required and was satisfied”. One relative spoke about his experience and said that he chose this home “because it is homely” and he thought “the staff were friendly and would be nice to his wife”. St Margaret`s Care Home (Nursing) DS0000026119.V359461.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team meets the health and personal care needs of the service users and their privacy and dignity are respected. The home have a good track record of responding to advice from other health professionals. EVIDENCE: Nurses complete the individual care plans based on the assessment. It is then updated with any information received including what has been reported to them by care staff. The plan sets out action that needs to be taken by nursing and care staff. A sample of 2 care plans was viewed and both were well documented. Risk assessments were seen for skin care, moving and handling needs and prevention of falls. The plans were either signed by the resident or a relative. Residents spoken with said that they had agreed to what was in their plan. Additional advice and intervention is sought from other health professionals. The nurses incorporate advice from other professionals into the care plans. Information was included from the physiotherapist, dietician, hospice nurse, St Margaret`s Care Home (Nursing) DS0000026119.V359461.R01.S.doc Version 5.2 Page 11 continuing care co-ordinator and speech and language therapist. The inspector received some commission surveys, that had been sent out, from visiting professionals prior to this visit. Examples of comments received: “Always looking to improve their service. They are informed and knowledgeable. They are always helpful and communicate well between service users.” And “Very good at referring patients with speech and language problems and following advice given.” Continence promotion is practised and records maintained of continence assessment and management. An additional member of staff has been trained for continence management so there are now three staff guiding staff in this area. The home has a good relationship with the GP’s and care managers as well as nurses and social worker staff at the local hospice. Following psychiatric referral, the home is further supported by the mental health team. At present none of the residents self- medicate but are assisted to take their medication. The policy for ‘as required’ medicines has been updated and made clearer for all nurses. A sample of medication administration charts were viewed and had been neatly and accurately completed. A new medicine fridge has been purchased. Medication storage was viewed including controlled medication. Correct procedures are in place for the disposal of unused medication including controlled drugs. The manager said she carries out a monthly medication audit. All surveys received said that residents’ privacy and dignity were respected. St Margaret`s Care Home (Nursing) DS0000026119.V359461.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are given the opportunity to take part in a variety of activities arranged in the home but some would benefit from more one-to-one activities and opportunities to go out. EVIDENCE: The home employs 2 activities coordinators who plan activities for the month. Residents spoke about the recent Easter Bonnet competition and there were photos of this and other events on the notice board in the entrance hallway. A newsletter is sent out quarterly to give people information about the home as well as planned activities. Some of the residents and two visiting relatives said that the group of singers that recently came to the home were really good. The lounge is quite small and is also used as the dining room at meal times. Most people said they prefer to stay in their rooms and some of the residents had visitors in their rooms. The home provides a range of activities and some residents said that they have gone out in a wheelchair when the weather is good. Opportunities for this are limited due to the needs of the people living in St Margaret`s Care Home (Nursing) DS0000026119.V359461.R01.S.doc Version 5.2 Page 13 the home and what the staff need to do. The manager agreed that it would be good to consider ways that opportunities to go out and have individual activities could be increased. There were visitors coming and going and looked like they could all visit freely. Staff encourage residents to have their meals in the dining room and the majority of the residents do. The inspector had lunch with some of the residents who were happy to chat about their lifestyle. Menu sheets give choices for people to indicate what they want. Comments in surveys received about the food from residents: “There is a good variety – tasteful and well cooked”, “I find the meat here first class and there is plenty of it”. 2 menus were being filled in by residents and relatives during the tour of the home to choose for the following day. Some residents prefer to eat in their own room or are not well enough to come down to the dining room. Some residents are given soft or pureed food presented in an appetising manner. Care plans contain nutritional assessments and residents are weighed monthly. For some residents with poor appetites, special meals are provided and their weight monitored more frequently. Digital hoist scales have recently been purchased. A visiting professional commented about residents who need specially prepared food: “Sometimes a patient with cognitive problems will want to eat dangerous textures, staff are sensitive about this with the client and endeavour to explain”. St Margaret`s Care Home (Nursing) DS0000026119.V359461.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives feel confident that their concerns are taken seriously, investigated and acted upon and that they are safeguarded from abuse. EVIDENCE: On admission, residents are made aware of the complaint procedure contained in the service user guide. The complaint procedure is also displayed on the notice board in the entrance hall. The home keeps a complaints file. There have been 8 complaints. The file was viewed and recent complaints and outcomes were discussed with the manager. There were some comments from residents and relatives about the laundry. There have also been complaints about clothing going missing and being damaged. A comment in one survey said: “Washing clothes seems to be a bit of a problem. Whites come back a dirty grey colour. Sometimes the dresses and cardigans are left in the dryer too long. Also clothes get mixed up although they are labelled.” The manager’s response to these issues had been logged in the complaints book. All the staff have attended adult protection training. Staff spoken to were knowledgeable about safeguarding issues. St Margaret`s Care Home (Nursing) DS0000026119.V359461.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and comfortable. Space is inadequate for all the physical needs of the residents but the manager has plans to address this. EVIDENCE: A tour of the home was carried out with the lead nurse. Since the last inspection visit various areas of the home have been decorated and some new carpet has been laid in the hallway. The bathrooms are small. One of the bathrooms is not currently being used because it has a specialised Jacuzzi bath that is out of use. This bathroom is needed. Shortly after the inspection visit, one of the owners explained the changes planned to make this bathroom useable. St Margaret`s Care Home (Nursing) DS0000026119.V359461.R01.S.doc Version 5.2 Page 16 The manager has reviewed the equipment needed to assist with residents’ mobility. Since this a new hoist has been purchased. The plans for the new extension include installing relevant facilities and equipment like wet rooms and lifting equipment. All the residents spoken to made positive comments about the home. They tend to spend the majority of their time in their rooms. Rooms looked comfortable and homely. The home employs domestic staff who keep the home clean. commented in a survey: “the home is spotless”. One service user The home has a very small laundry. Storage of clean clothes and linen is a problem due to lack of space in the laundry and has to be stored in the hallways. The washing machine was unreliable in the winter months. There were complaints in the complaints file and comments in surveys received that indicate that the washing machine was a problem. It was acknowledged that new laundry facilities were included in the owners building plans for the extension, however it was agreed with the manager that the laundry needs to be improved as soon as possible. There were also comments about the standard of washing and about items of clothing going missing. The manager had responded to individual complaints. Laundry is currently carried out by the housekeeper in the morning and the carers in the afternoon. St Margaret`s Care Home (Nursing) DS0000026119.V359461.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using services are very satisfied with the care they receive to meet their needs but there are times when they may need to wait a short time for staff support and attention. EVIDENCE: The manager is supported by two senior sisters and other trained staff. The home is an accredited training centre for 1st year student nurses. Residents said that they liked the staff who were kind, thoughtful and caring. Some residents did say that they thought the staff have a lot to do and surveys indicated that some people thought it would be better if there were more staff. Examples of comments in surveys from residents and a relative: “the staff are very supportive”, “considering what they have to do they do very well” and “there are times when staff are attending other patients but they always come at the first opportunity”. There was a discussion with the manager about this. The rota was viewed. Different staff are employed to work as carers, activities co-ordinators, kitchen staff, housekeepers and for building maintenance support. There are also a number of flexi staff who are available to work when needed. The manager said she would discuss the staffing with the owners and look at where improvements need to be made. St Margaret`s Care Home (Nursing) DS0000026119.V359461.R01.S.doc Version 5.2 Page 18 The manager said this will be monitored through the staff meetings and the quality monitoring systems. Three care staff spoke about their experiences in the home. One person spoke about the recruitment process. They have completed the skills for care induction and some of the initial mandatory training. Staff were positive about the home and reflected the views of residents and relatives. A sample of 2 staff files were viewed and records checked. The home had made sure all the checks such as CRB/POVA and references had been carried out before they had started work. The manager said she would like to involve residents in the recruiting process more. At present their involvement is being introduced to prospective members of staff and they can make comments having talked to them. The home has a well established NVQ training programme. Over half of the care staff in the team have achieved the NVQ level 2 or above. The training matrix was on the wall and clearly showed all training completed and planned. Senior carers have completed palliative care training. The manager attended a refresher in moving and handling trainer training during the morning of the visit and along with two nurses delivers moving and handing training to the staff team. Staff spoke about the training they had received. Staff are encouraged to supervise and train newer members of staff in a structured way. St Margaret`s Care Home (Nursing) DS0000026119.V359461.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has good people skills and a clear understanding of the key principles and focus of the service. There is an atmosphere of openness and respect in which residents and relatives feel their opinions matter and where the safety and welfare of residents is most important. EVIDENCE: The home is managed by Mrs Amanda Atkins. She is a first level nurse with extensive experience of caring for older people and has completed her NVQ level 4 in management. Comment in survey from visiting professional: “Has excellent matron in post who has made changes to improve the service at the home.” Mrs Atkins has an open management style and staff and residents said that they regard her highly. St Margaret`s Care Home (Nursing) DS0000026119.V359461.R01.S.doc Version 5.2 Page 20 The home has a quality assurance system in place. The manager said that completing the AQAA would also be part of this process from now on. Plans for improvement were included in the AQAA. The owners visit the home regularly and produce a monthly quality assurance report. Quality survey forms are given out by the home to enable residents, visiting professionals and relatives to make comments and provide feedback. One of the visiting relatives also commented on her experiences of the home. She said that it had been recommended. She had been to other homes but this one was the nicest. She said it had a good atmosphere and the staff were really caring. The manager oversees the management of service users’ personal pocket monies. All transactions are recorded, and receipts are retained. Relatives are invoiced monthly for payments for hairdressing, chiropody and newspapers. It is evident that safety checks in respect of equipment, gas, electricity and hot water supplies are undertaken at appropriate intervals. The CSCI is advised of reportable events without delay. St Margaret`s Care Home (Nursing) DS0000026119.V359461.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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 2 STAFFING Standard No Score 27 2 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 3 St Margaret`s Care Home (Nursing) DS0000026119.V359461.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Margaret`s Care Home (Nursing) DS0000026119.V359461.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Margaret`s Care Home (Nursing) DS0000026119.V359461.R01.S.doc Version 5.2 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!