Inspection on 12/03/08 for The Marguerite Centre

This inspection was carried out on 12th March 2008.

CSCI found this care home to be providing an Excellent 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.

Other inspections for this house

The Marguerite Centre 27/09/06

The Marguerite Centre 15/02/06

The Marguerite Centre 11/04/05

The Marguerite Centre 20/12/04

The Marguerite Centre 05/04/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE The Marguerite Centre The Royal Bucks Hospital Buckingham Road Aylesbury Buckinghamshire HP19 9AB Lead Inspector Joan Browne Unannounced Inspection 12th March 2008 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Marguerite Centre DS0000019241.V359588.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. The Marguerite Centre DS0000019241.V359588.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Marguerite Centre Address The Royal Bucks Hospital Buckingham Road Aylesbury Buckinghamshire HP19 9AB 01296 678800 01296 678800 jan@royalbucks.co.uk www.rehab@royalbucks.co.uk Mr J Clarke Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Janet Sillitoe Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (5) of places The Marguerite Centre DS0000019241.V359588.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the home provides care for Physically Disabled service users over 45 years of age. That the home provides Respite Care. That the home provides Intermediate Care. Date of last inspection 27th September 2006 Brief Description of the Service: The Marguerite Centre is a care home with nursing, situated within the Royal Buckinghamshire Hospital. The hospital is close to Aylesbury town centre offering level access to restaurants, a library, a shopping centre, cinema and other local amenities. It offers long-term nursing, respite and intermediate care to people over the age of forty-five, including married couples. The home is on the first floor of the Royal Buckinghamshire Hospital and is on one level, making it wheelchair accessible. Access to the home is via a passenger lift. There is always a registered nurse on duty supported by healthcare assistants. The current scale of weekly charges range from £462.91- £850.00. Additional charges are made for Chiropody, hairdressing and newspapers. The Marguerite Centre DS0000019241.V359588.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 3 star. This means the people who use this service experience excellent quality outcomes. This inspection of the service was an unannounced key inspection. We arrived at the service at 09.15 am and the inspection lasted for approximately six hours. This inspection was a thorough look at how well the service is doing. It took into account information provided by the service’s manager in the annual quality assurance assessment (AQAA) and any information received about the home since the last inspection. We saw most areas of the home and looked at records and documents relating to the care of the people using the service and staff members. Staff’s practice was observed. We asked the views of the people who use the service and other people seen during the inspection or who responded to questionnaires that we sent out and their views are included in this report. We looked at how the service was meeting the standards set by the government and in this report made judgements about the outcomes for people living in the home. From the evidence seen and comments received we considered that the home was ensuring that people using the service diverse needs were being met. One recommendation was made and this can be found at the end of the report in the recommendation section. We (the Commission) would like to thank all the people living in the home, visitors and staff who made the visit so productive and pleasant on the day. The final part of the visit was spent giving feedback to the manager about the findings of the visit. What the service does well: The home ensures that prospective people to use the service needs are assessed before agreeing admission to the home. People living in the home have a care plan to ensure that their health and personal care needs would be met. The Marguerite Centre DS0000019241.V359588.R01.S.doc Version 5.2 Page 6 The home provides an activity programme to ensure that people living in the home can be supported to follow their personal interests and activities. The home has a complaints procedure to ensure that people living in the home and their relatives are able to raise any concerns. The home ensures that people using services are provided with the appropriate aids and equipment to maximise their independence. The home ensures that the appropriate numbers and skill mix of staff meet people using services changing needs. The home has a quality assurance system in place to ensure that it is run in the best interests of people using the service. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. The Marguerite Centre DS0000019241.V359588.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 The Marguerite Centre DS0000019241.V359588.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Before agreeing admission the home carefully considers the needs assessment for each prospective person to ensure that it is able to meet his or her diverse needs. EVIDENCE: The home’s annual quality assurance assessment (AQAA) stated that it provides prospective residents with a personal assessment and an opportunity to visit the home wherever possible. The pre-admission assessment details for a resident recently admitted to the home were checked and detailed information of all aspects of the individual’s health care needs were recorded. The home ensures that all prospective residents receive a brochure, which tells them about the provision of care. Residents who participated in the Commission’s survey said that they had received enough information about the home, which enabled them to decide it was the right place for them. The Marguerite Centre DS0000019241.V359588.R01.S.doc Version 5.2 Page 9 We were told that experienced staff members with skill and sensitivity undertake assessments. The home would ensure that a summary of any assessment undertaken through care management is always obtained. The manager was able to demonstrate how the home was meeting the ethnicity and diversity of the community it serves. On the day of the inspection the home was expecting to carry out a joint assessment with Social Services on a person whose first language was not English and the services of an interpreter was being used. There was no one on the day of the inspection in receipt of intermediate care. The home stated in its annual quality assurance assessment (AQAA) that it has a strong desire to develop its intermediate care facility by providing in-house therapy services. Negotiations were currently taking place with the various funding authorities. The Marguerite Centre DS0000019241.V359588.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): 7, 8, 9 & 10 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has a system in place to ensure that the health and personal care that people receive is based on their diverse needs. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity EVIDENCE: Three residents’ care plans were looked at in detail. Plans were of a standard format addressing core areas of need such as, hygiene, bowel management, bladder and catheter management, nutrition, pressure sore prevention, rehabilitation, social history, sight, hearing, breathing and sleeping. Waterlow, manual handling and nutritional risk assessments were in place. Plans seen were concise and easy to follow and reflected the plan of care in place to ensure that needs were being met. The care plans were signed and dated by the staff member completing it. Residents’ signatures were not evident but there was a written statement confirming that the residents had been consulted with the development of the plans. The Marguerite Centre DS0000019241.V359588.R01.S.doc Version 5.2 Page 11 Daily records inter-related with the care plan and individuals’ care needs were being evaluated at least three times daily or as and when required. The key nurse was able to describe how the home was meeting individuals’ changing needs. In the case of one particular resident who was not able to speak the nurse demonstrated how she communicated with the individual and responded effectively to changes in the individual’s mood, behaviour and general wellbeing to ensure that they were acted on. Residents, relatives and health care professionals who responded to the Commission’s survey said that the home ‘always’ provided the appropriate care and support. The following additional comments were noted: ‘I never have any concerns that only the best care is provided. I would not say this about any other home in the area.’ All permanent residents are registered with a general practitioner (GP) who visits the home weekly. Arrangements were in place to ensure that respite residents can receive medical treatment if needed. Professional advice on the promotion of continence is sought and acted upon. Aids and equipment are provided to encourage maximum independence, which are regularly reviewed and replaced to accommodate changing needs. Specialist advice is sought by the home to ensure effective use of equipment. Staff spoken to said that they regularly update their knowledge and skills in health care matters such as tissue viability and catheter care. We were told that there were no residents in the home with pressure sores and the home is commended for providing a high standard of care. The home’s annual quality assurance assessment (AQAA) stated ‘that with the increased numbers of respite residents staff who have needed support and education in providing a flexible approach to their work have been supported in supervision by more experienced nursing colleagues. Nursing staff have been supported in adapting to the requirements of rapid response of a frequently changing population within the home.’ This should ensure that residents’ health care is promoted and maintained to a high standard. Health care professionals who responded to the Commission’s survey said that the home ‘always’ seek advice and act upon it to manage and improve individuals’ health care needs. There were no residents on the day of the inspection who were able to selfmedicate. The medication administration record (MAR) sheets were examined and there has been an improvement in staff’s recording practice. No unexplained gaps were noted on the MAR sheets and medication was satisfactorily stored. There was a limited amount of medication in the stock cupboard, which meant that the home was ordering only what was required. It was noted that some MAR sheets were handwritten and on one particular medication sheet the frequency and dose of the medication had been amended. To comply with best practice guidelines it is recommended that handwritten MAR sheets and any amendments made should be checked by a second person to minimise the risk of error when transcribing. The controlled drug medication was checked and tablets in the packets corresponded with the The Marguerite Centre DS0000019241.V359588.R01.S.doc Version 5.2 Page 12 register. Two staff members signed all entries to the controlled drug register and a record is maintained for all drugs disposed of. Staff were observed interacting with residents in a kind, sensitive and respectful manner. Residents’ appearance and attire were clean and tidy with attention to detail. Staff were observed responding appropriately when providing personal care, ensuring that it was conducted in private and not rushed. Staff spoken to were able to demonstrate how they were meeting residents’ changing needs and was knowledgeable about individuals’ diverse needs. Those residents who responded to the Commission’s survey said that staff ‘always’ listen and act on what is said. The Marguerite Centre DS0000019241.V359588.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use 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 home ensures that people who use services are involved in meaningful activities of their own choice and according to their individual interests, diverse needs and capability. Meals provided are wholesome and appealing served in pleasant surroundings. EVIDENCE: The home’s annual quality assurance assessment (AQAA) stated that ‘within each individualised care plan provision is made for the residents to choose times for their routines of daily living.’ Residents spoken to confirmed that the home’s daily routine was flexible and they were able to choose how they wished to spend their day. The home has an activity organiser who provides activities four times a week. Activities such as bingos, quizzes, board games, shopping trips to the town and one to one activities are provided. There is also a volunteer who facilitates some activities on a Wednesday afternoon Entertainers are brought into the home periodically and a ‘pet as therapy’ (PAT) dog visit occasionally. The AQAA reflected that the activity programme had improved in the last twelve months because the The Marguerite Centre DS0000019241.V359588.R01.S.doc Version 5.2 Page 14 activity organiser had undertaken training, which had assisted her in providing a more varied programme. A record was now being maintained of residents participating in activities. Those residents who responded to the Commission’s survey said that there was ‘always’ activities arranged by the home that they can take part in. Staff support residents to maintain contact with family and friends and in turn they become well known to family members and friends. Relatives who responded to the Commission’s survey said that the home ‘always’ helped their relative to keep in touch with them. The following additional comments were noted: ‘staff care for residents like family members’. Those residents spoken to during the inspection said that staff always made their visitors feel welcome and offered them refreshments. We were told that residents who wish to promote their religious needs every effort is made to enable them to do so. Residents’ individual choices and needs were reflected in their care plans. Residents choose what clothes they wish to wear and if they wish to spend time alone. There were no residents using the services of an advocate on the day of the inspection. Some residents’ bedrooms had personal items of furniture such as chairs and chest of drawers, which confirmed that residents are made aware that they are entitled to bring personal possessions with them if they wished to. Residents are offered a choice of varied menus that meet their cultural and dietary needs. There are two choices on the main course and dessert to choose from daily. Residents spoken to said that lunch was tasty and the portions were adequate. Snacks and tea and coffee are on offer throughout the day. Special diets such as diabetic or soft can be catered for. Staff were sensitive to the needs of those residents who had difficulty to eat and offered assistance in a comfortable and unhurried manner. The Marguerite Centre DS0000019241.V359588.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use 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 home has systems in place to ensure that if people have concerns about their care they know how to complain and they are protected from abuse and have their rights protected. EVIDENCE: No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. We were also told that the home had not received any complaints about the service. The home’s annual quality assurance assessment (AQAA) said that ‘the home had robust policies on dealing with concerns and complaints.’ Staff are expected to undertake training in an awareness of customer care, which should help them to develop the capacity and confidence to address issues of concerns. Residents and relatives who responded to the Commission’s survey said that they knew how to make a complaint. Those spoken to on the day of the inspection said that they had never had to make a complaint. The Commission has not received any information concerning any suspicion or evidence of abuse or neglect made to the service since the last inspection. The Marguerite Centre DS0000019241.V359588.R01.S.doc Version 5.2 Page 16 The home’s AQAA stated that ‘staff receive training in the safeguarding of vulnerable adults and the home’s policies on abuse and whistle blowing were being continuously reviewed.’ Staff spoken to confirmed that they had undertaken training in the safeguarding of vulnerable adults and were aware of the action, which should be taken if they suspected or witnessed any incident of abuse. The Marguerite Centre DS0000019241.V359588.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use 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. People stay in a home, which is safe, clean, pleasant, hygienic and well maintained. They are provided with the right specialist equipment to maximise their independence. EVIDENCE: The home is situated on the first floor of the old Royal Buckinghamshire Hospital and has been adapted for its present use as a nursing home. All rooms are single occupancy and are fitted with wash hand basins. Residents are encouraged to personalise their bedrooms. All the home’s fixtures and fittings meet the needs of the individual and can be changed if their needs change. Suitable equipment is provided to residents with serious physical disability to assist and enable safe moving and handling to be carried out. The home stated in its annual quality assurance assessment (AQAA) ‘that plans were in place to adapt an existing bathroom into an easy access wet room with The Marguerite Centre DS0000019241.V359588.R01.S.doc Version 5.2 Page 18 shower and toilet.’ We were told on the day of the inspection that the work had been completed. Three specialised shower commodes had also been purchased to ensure that residents’ dignity were maintained when staff were providing personal care. There is a planned maintenance programme in place and the home was in a good state of decorative order. At the previous inspection a requirement was made for radiators in the lounge, dining areas and residents’ bedrooms to be fitted with covers. It is pleasing to report that the requirement had been complied with. The home has infection control policies and procedures in place and appropriate hand washing facilities and gels were available. We were told that the home had recently experienced a ‘noro virus’ outbreak and was commended by the health protection agency for containing the spread of the infection. The virus subsided within seven days and it was evident that staff had worked to the home’s policy. All carpets, curtains and walls were deep cleaned to prevent the risk of the infection spreading further. On the day of the inspection the home was well lit, clean, tidy and free from odours. Residents and relatives who responded to the Commission’s survey said that the home was ‘always’ fresh and clean. Additional comments such as, ‘the home is tip top.’ ‘The home is very clean and is running very efficiently’ were noted. There is a well-organised laundry in the basement of the building and washing machines are equipped with the specified programming ability to meet disinfection standards. Residents and relatives spoken to on the day of the inspection said that the laundry facilities were satisfactory. The Marguerite Centre DS0000019241.V359588.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use 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 home ensures that people using services diverse needs are met by staff who have been appropriately trained and recruited EVIDENCE: The home employs a multicultural staff group to meet the diverse needs of residents. The home’s annual quality assurance assessment (AQAA) stated ‘that the home had a high ratio of trained nurses and health care assistants.’ We discussed the staffing rota and gave feedback to the manager on comments made in the survey. We were told that seven staff are rostered to work in the morning. This number is reduced to five in the afternoon and two at night. The manager was confident that the home was staffed efficiently, with particular attention given to busy times of the day and changing needs of the people who use the service. Residents and relatives spoken to on the day of the inspection said that ‘staff were caring and kind.’ Staff spoken to were very proud of the high standard of care they were providing. The home is fully committed to training care staff to meet residents’ needs. More than 50 of the staff team had achieved the national vocational qualification (NVQ) in level 2 and 3 in direct care. The Marguerite Centre DS0000019241.V359588.R01.S.doc Version 5.2 Page 20 The home has a good recruitment procedure, which is followed in practice to ensure the protection of residents. The recruitment files of three new members of staff were examined. Files had the required information and all staff were in receipt of an enhanced criminal record bureau clearance. The home ensures that all new staff receive induction training to assist them in understanding their roles and responsibilities. There is a training programme in place to ensure that mandatory training for all staff is regularly updated. Staff who responded to the Commission’s survey said that their training needs were regularly updated. We were able to attend a staff meeting that take place regularly. Notes and action points are taken of meetings and staff find them helpful with a focus on improving outcomes for residents. The Marguerite Centre DS0000019241.V359588.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 35 & 38 People who use 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. People have confidence in the care home because it is run in their best interests and their health, safety and welfare are promoted and protected EVIDENCE: The manager is a registered general nurse and has over ten years experience of managing a care home. She manages another registered service on the same site and holds a post-graduate qualification in elderly care. She regularly undertakes periodic training to update her knowledge, skills and competence. A clinical lead nurse, registered nurses and health care assistants support the manager in the day- to- day running of the service. The Marguerite Centre DS0000019241.V359588.R01.S.doc Version 5.2 Page 22 There is a strong ethos of being open and transparent in all areas of running the home. Equality and diversity issues are focussed on and residents’ dignity is promoted. The home has a quality assurance programme in place, and a clinical governance committee and health and safety committee, which oversee quality improvements in the home. Monthly residents’ satisfaction surveys are sent out and the results are acted on when necessary. Twenty-four comment cards were received in connection with this inspection. Five from residents, five from relatives, six from staff and eight from health and social care professionals. All resident respondents said that they liked living in the home. Felt well cared for, felt well treated by staff, and knew who to complain to if they were unhappy. All liked the food as well. Relatives and health care professionals were equally positive in their views and were overall satisfied with the care provision. Comment cards demonstrated a high level of satisfaction with the home. Residents’ financial affairs are managed by their families. Where residents choose to leave a small amount of money with the home, for expenditure such as hairdressing, newspapers and chiropody, this is deposited in a bank account and records are kept detailing expenditure made on behalf of residents. The home has health and safety policies and systems in place for the regular maintenance of equipment. A spot check was carried out on the fire panel and the hot water temperature records. These were being satisfactorily maintained, which meant that residents’ safety and welfare are promoted and protected. The Marguerite Centre DS0000019241.V359588.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 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 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 3 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 3 X X 3 The Marguerite Centre DS0000019241.V359588.R01.S.doc Version 5.2 Page 24 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 The Marguerite Centre DS0000019241.V359588.R01.S.doc Version 5.2 Page 25 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 The Marguerite Centre DS0000019241.V359588.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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