Care Home: Marlborough House Nursing Home

What the care home does well This is an improving home that has recently undergone a large programme of refurbishment. The improvements are nearing completion and they will enhance the home for the benefit of the service users. The home is good at assessing new service users to make sure their needs can be met and then at detailing those needs in useful care plans that the staff use to care for individuals. The staff are good at making sure all the service users have their health care needs met. They are also caring and respectful. A particular strength of this home is the amount and variety of activities that people can choose to participate in. This is due to the activities co-ordinator who makes sure that people are included in group activities or that they have individual time to pursue their interests or just to have company and a chat.The majority of staff have been at the home for some time so they know people well and they are able to do their best to meet their needs. The matron is aware of what needs to be done to improve the home and steps are being taken to address any areas where improvements need to made. A relative said that some staff were really good at making sure the service user had their glasses cleaned and the extra details that made their relative comfortable. One service user said the staff always did their best and they were kind and talked to the service users. What has improved since the last inspection? The homes environment has improved and this will continue until the home is fully redecorated. All of the previous requirements have been complied with or the matron is working towards meeting them to improve the outcomes for the service users. All the service users have new beds that suit their needs and they said these were comfortable. New equipment has been purchased to assist the staff to safely care for the service users. Staff training is beginning to improve as well as the frequency of staff supervisions. The matron has managed to restructure the roles within the home so that they can concentrate on the overall management and so that different staff are clear about their responsibilities. This continues to improve the service for the benefit of the service users. What the care home could do better: No new requirements have been made because the plans to address all of the following issues were discussed and agreed with the matron or recorded in the AQAA and the matron is aware that the following issues need addressing. They include: 1. The need to make sure all areas of the home are odour free.2. That all equipment is kept in working order or replaced when broken, this includes the pedal bins in the two main bathrooms. 3. That all staff continue to update their training. 4. That all staff are regularly supervised. 5. That all new staff receive a full induction. CARE HOMES FOR OLDER PEOPLE Marlborough House Nursing Home 241 Aldershot Road Church Crookham Fleet Hampshire GU13 0EJ Lead Inspector Kima Sutherland-Dee Unannounced Inspection 11:25 30th July 2008 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.V367570.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.V367570.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.V367570.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 12th July 2007 Date of last inspection Brief Description of the Service: Marlborough House is a nursing home providing nursing for up to 47 older people. The home is owned by Hestia Care Ltd Limited and it is located on the outskirts of Fleet and close to the village of Church Crookham and the local amenities. The establishment comprises 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 the building have 2 stories with a passenger lift in both wings. Since the recent refurbishment all the rooms now have ensuite facilities. The home has a garden that can be accessed by wheelchair users, with a new decked area and pathways. There is a range of communal rooms throughout the establishment including a large new lounge, dining room and kitchen. The fees at the home range between £561 - £850 per week for those who need nursing care, depending on their needs and their chosen accommodation. The fees do not include hairdressing, chiropody and other personal items. Marlborough House Nursing Home DS0000012228.V367570.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. The inspection included a site visit to the home over a period of five hours and twenty minutes, with a twenty minute break. During this time the registered manager who is known as the matron , the staff, a relative and five people who live in the home were spoken with and the care was observed. Care plans, training records, policies and staff records were sampled. A tour of the home took place to see the refurbishments and the improvements to the environment. Other information used to make judgements about the standard of care in the home included the last inspection report and information received from the home including their Annual Quality Assurance Assessment (AQAA) completed by the manager. This was received within the timescale requested by the commission. These have been referred to throughout the report. What the service does well: This is an improving home that has recently undergone a large programme of refurbishment. The improvements are nearing completion and they will enhance the home for the benefit of the service users. The home is good at assessing new service users to make sure their needs can be met and then at detailing those needs in useful care plans that the staff use to care for individuals. The staff are good at making sure all the service users have their health care needs met. They are also caring and respectful. A particular strength of this home is the amount and variety of activities that people can choose to participate in. This is due to the activities co-ordinator who makes sure that people are included in group activities or that they have individual time to pursue their interests or just to have company and a chat. Marlborough House Nursing Home DS0000012228.V367570.R01.S.doc Version 5.2 Page 6 The majority of staff have been at the home for some time so they know people well and they are able to do their best to meet their needs. The matron is aware of what needs to be done to improve the home and steps are being taken to address any areas where improvements need to made. A relative said that some staff were really good at making sure the service user had their glasses cleaned and the extra details that made their relative comfortable. One service user said the staff always did their best and they were kind and talked to the service users. What has improved since the last inspection? What they could do better: No new requirements have been made because the plans to address all of the following issues were discussed and agreed with the matron or recorded in the AQAA and the matron is aware that the following issues need addressing. They include: 1. The need to make sure all areas of the home are odour free. Marlborough House Nursing Home DS0000012228.V367570.R01.S.doc Version 5.2 Page 7 2. That all equipment is kept in working order or replaced when broken, this includes the pedal bins in the two main bathrooms. 3. That all staff continue to update their training. 4. That all staff are regularly supervised. 5. That all new staff receive a full induction. 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. Marlborough House Nursing Home DS0000012228.V367570.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 Marlborough House Nursing Home DS0000012228.V367570.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): 1,2,3,5 Quality in this outcome area is good. Prospective service users have the information they need to make an informed decision before moving to this home. Service users benefit from having their needs assessed and being offered a contract including the homes terms and conditions. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Prospective service users are given information about the home and then invited to visit. The manager said that the staff are trained to reassure the service users and their relatives about any move to the home. The matron also said they always suggest that Service users look at a number of different homes so they can make an informed decision. Marlborough House Nursing Home DS0000012228.V367570.R01.S.doc Version 5.2 Page 10 When a new service user moves in the staff will have made sure the room is ready and people are greeted with a card and flowers to welcome them to the home. The last inspection report included a requirement to ensure that all the service users had contracts that were signed. This requirement has been complied with. The manager explained that all the service users now have signed contracts and random samples of four contracts were seen. Each service user is also given a Service Users Guide with details of the home and the terms and conditions of their stay. Before a service user moves in the matron or trained staff will visit the person and make an assessment of their needs. Four pre admission assessments were seen and they were detailed, the information from these are then used to develop a care plan within a week after admission. The assessment is in the process of being improved. Marlborough House Nursing Home DS0000012228.V367570.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good. The service users health, personal and social needs are met and these are recorded in individual care plans. The staff treat people with respect and dignity. The service users benefit from safe medication storage, administration and recording. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five care plans were seen and they had the information that the staff needed to care for each person including peoples likes and dislikes and routines. There was documentary evidence that care plans were reviewed monthly or if the resident’s condition had changed. The care plans detailed the service users needs and how these should be met and they were individual to each person. They included risk assessments on Manual handling, Nutrition, and skin Marlborough House Nursing Home DS0000012228.V367570.R01.S.doc Version 5.2 Page 12 condition to prevent pressure sores. The new care director is in the process of improving the care plans and the staff are being trained to use the new plans. The care plans included a family tree which gave details about peoples past histories and interests. The care plans also had a record of any healthcare visits and a record of the care given each day. One service user said that the staff were helping to arrange dental treatment and a appointment had been made. A relative also said the G.P had visited the day before, but it would have been useful if the staff had informed them of this visit. This relative also said that the staff do look after the service user and ‘ They are keeping a close eye on their skin’ This is because the service user is in bed but the staff have got the appropriate pressure relieving equipment to prevent sores developing, and details are recorded in the care plan. This relative also said that some staff were really good at making sure the service user had their glasses cleaned and the extra details that made their relative comfortable. The staff record each persons weight, blood pressure and temperature at least every month to monitor their health. The medication procedures were seen as well as their storage and recording. A trained member of staff explained how they administer and store medication and the records were seen to be correct. The care was observed during the day and the staff were seen to be kind and caring. The staff spoke to people respectfully and they maintained the service users dignity when offering care. One service user said ‘ The staff are busy but they are very nice and they do talk to me’. Marlborough House Nursing Home DS0000012228.V367570.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 Quality in this outcome area is good. The service users have the choice to participate in a wide range of activities and to maintain contact with their family and friends. The service users benefit from a choice of food that meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a person solely to organise and undertake activities in the home. They attend the home five days a week. The activities programme was displayed on both floors and the advertised activities took place during the day. The programme demonstrated a variety of group activities. The coordinator explained how they meet the needs of people who choose not to or are unable to participate in group activities. The co-ordinator will visit them in their room to do crosswords or read or just chat. Each person has a separate care plan that records their interests and hobbies and then it details how the co-ordinator can meet their needs and expectations. Marlborough House Nursing Home DS0000012228.V367570.R01.S.doc Version 5.2 Page 14 One service user explained that although they choose not to participate in group activities the co-ordinator accompanies them into town to shop and have a coffee. The co-ordinators role is a particular strength of this home and provides excellent outcomes for the service users, as it means that people are kept busy if they choose. The co-ordinators interactions with the service users were positive, friendly and encouraging, they obviously knew people well. In the afternoon 5 people were helped to sit in the garden and play a game of dominoes. During the game people were laughing, chatting and enjoying an ice cream. One care plan recorded that a service user enjoyed reading and old films, the activities co-ordinator makes sure this person can access the regular mobile library and they supply old films, they said they will do whatever suits the service users needs or medical condition. The AQAA reports that the activities organiser maintains a diary of events and of the service users who are seen individually. This means they can allocate their time effectively and it ensures that everyone has time to take part in a range of activities. The AQAA states that the recent refurbishment is nearing completion and the home will then have a fully equipped hairdressing room, better garden access and improved communal facilities. One service user said they were looking forward to the work being completed but it hadn’t caused them disruption. The care plans record peoples religious beliefs and they are able to continue to worship through church services at the home or going to their chosen church. The AQAA states that the service encourages family and friends to join in with activities and there is an open visiting policy. The service will restart service user and family meetings when the refurbishment is completed. Visitors were seen around the home and one kindly spoke about their relatives care, they were generally positive about the service. The manager explained that the previous cook had just left, and a trained carer had temporarily taken over the role. The service users and the manager said there had been an improvement in the food recently. The cook asks the service users each day about their menu choices and alternatives are available. The service users likes and dislikes are recorded and people receive a diet that suits their needs. One relative said they had seen the staff offering alternative food if the service user indicated they didn’t like a meal. Service users are eating their meals on trays in the upstairs lounge or in their rooms but the environment for meal times will improve when the new dining room is completed in the next two weeks Marlborough House Nursing Home DS0000012228.V367570.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): 16,17,18 Quality in this outcome area is good. The service users can feel confident that their complaints will be responded to appropriately. The service users benefit from staff who have been trained to protect them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA states that the service has a clear complaints procedure and this was seen in the ‘Service Users Guide’ Two service users said they would speak to matron if the had a complaints. Complaints procedures are monitored during the monthly visits to the home to ensure they are effective. One complaint has been received since the last inspection and the complainant also spoke to social services and the commission. This complaint was dealt with appropriately by the home and meetings were held with the complainant to try to resolve the concerns. The service has a policy regarding the rights of the service users to see their personal files and the service users or their relatives are informed about this. There is also a policy about the rights of individuals to worship in their chosen faith and their rights to privacy and dignity. Marlborough House Nursing Home DS0000012228.V367570.R01.S.doc Version 5.2 Page 16 The staff had received training in July 2008 in the ‘protection of vulnerable adults’, and two members of staff demonstrated that they would act appropriately if they suspected abuse. There are leaflets about the prevention and reporting of abuse on the reception hall notice board. Marlborough House Nursing Home DS0000012228.V367570.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): 19,22,24,26 Quality in this outcome area is adequate. The service users live in a home that is being improved and will soon offer better facilities and enhanced private and communal areas. The home is generally kept clean and safe, but improvements need to be made in one area of infection control and one of odour control. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has recently been refurbished providing all single rooms with ensuite facilities, a new extension with a large lounge dining room and a new fully equipped professional kitchen. A new large passenger lift has been installed so that the service users in both areas of the home have access to the first floor by lift. This work is nearing completion and the provider explained that the Marlborough House Nursing Home DS0000012228.V367570.R01.S.doc Version 5.2 Page 18 main work should be finished in the next two weeks. After this the older part of the home will be redecorated. The service users who have stayed at the home during the work said they had not been disrupted, although some people had moved rooms temporarily. The numbers of service users living in the home had been greatly reduced to nineteen during the work and some people who have moved to other homes will return soon. The last report included a requirement to ensure that where bed rails were used they needed to have protective coverings. All beds have now been replaced and no bed rails are in use. The service users were seen to have the equipment they needed to maintain their independence or to assist them with their mobility. Two new hoists have recently been purchased and the matron discussed the possibility of a specialised wheelchair for one service user. One service user already has a customised wheelchair that assists them to access the home and to feel comfortable. The home was clean and domestic staff are employed during the week and at weekends. It was noted that two bins for clinical waste in the bathrooms did not work by using the foot pedals. This could present an infection control risk and the matron said they would be replaced within two weeks. The staff have had infection control training and they were seen to wear protective clothing for personal care. It was noted that there was an unpleasant odour in one corridor. The matron immediately discussed this with other staff so that it could be dealt with. A requirement was made at the last inspection to keep all parts of the home clean and free from offensive odours. The home is now clean and the matron gave a verbal assurance that action would be taken to prevent offensive odours reoccurring in the small affected area. The matron explained that there are now weekly meetings held with each department and the administrator is responsible for domestic staff but this is monitored. It is hoped this will clearly define the different roles and enable the staff to take on different responsibilities to improve the overall service for the service users. Samples of the bedrooms were seen and during discussions with one service user it was noted that they had many personal items. They said they liked their room and it was comfortable. The AQAA states that new service users are encouraged to bring their own possessions. Marlborough House Nursing Home DS0000012228.V367570.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 Quality in this outcome area is good. The service users are supported by a caring staff team who are available in the numbers required to meet their needs. The training and induction are not up to date but the management have plans to improve this. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three staff were spoken with, they said they generally had enough staff available to care for people and have time to chat to them unless they were particularly busy. The matron explained that during the refurbishment the staff numbers had reduced in line with the reduction in the number of service users. The matron is now in the process of recruiting more staff so that they are available when the work is finished and the service users move back in. There is always one trained nurse on duty as well as domestic staff and carers. The AQAA records that one member of staff out of eleven permanent staff have an National Vocational Qualification (N.V.Q) in care but the service aims to improve this over the next twelve months, and the majority of staff are interested in starting this training. Marlborough House Nursing Home DS0000012228.V367570.R01.S.doc Version 5.2 Page 20 The matron did say that they realised the staff induction wasn’t fully up to date but improvements have been made during the difficult time of the building works. Samples of five staff files were seen and they contained the correct recruitment checks and identification. The matron said that due to the building work over the last eight months they were aware that training had not been kept up to date but the new care director was correcting this. The training programme showed that staff had attended fire and manual handling training in the last two weeks and courses in advanced first aid, Good night care and assertiveness have been booked in the next three months. The service also uses an in-house training system that is then assessed externally and the care director is also training staff. Improvements are also being made to the system for inducting new staff, Three older induction packs were seen and they were not completed. The AQAA says that all new staff receive an induction pack and the matron said they were up dating this to include the standards in the ‘ Skills for Care’ induction. Marlborough House Nursing Home DS0000012228.V367570.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): 31,33,35,36,38 Quality in this outcome area is good. The home is managed effectively and in the service users best interests. The service users views are sought and improvements are made as a result. The service users benefit from a safe and well maintained home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is registered with the commission, is a qualified nurse and has been in post for eleven years. The staff said they were approachable and helpful. Marlborough House Nursing Home DS0000012228.V367570.R01.S.doc Version 5.2 Page 22 The AQAA states that the matron continues to up date their skills and they attended a Dementia course in June 2008. The matron explained that a new survey format had been used in November 2007 to gain the views of the service users, the surveys had been returned by January 2008 and the results had lead to improvements in the service, particularly regarding the standard of food. Quality is also monitored during the monthly visits on the provider’s behalf by an external consultant, who speaks to the service users and produces a report that is kept in the home. Following these visits they make recommendations to the management for improving the service. Service users meetings will recommence once the refurbishment of the home is completed. A number of thank you letters were displayed in the hallway and these praised the staff and matron for their care and support. The AQAA states that any service users money is kept securely and accounted for individually with records and receipts. The home has a policy on the safe keeping of service users monies and this was seen. The matron did say that they realised the staff induction wasn’t fully up to date but improvements have been made during the difficult time of the building works. The AQAA states that all staff were supervised or appraised during January 2008 and a new simple form has been developed. A random sample of staff files showed that a number of staff had had supervision and the three staff spoken with confirmed this. A requirement was made at the last inspection to supervise staff at least six times a year, the matron gave a verbal assurance that they are working towards full supervision for all staff. A sample of the homes policies demonstrated that they are regularly reviewed and up dated. The last review date was January 2008. Staff responsible for health and safety have had training or are in the process of training. Records show that all the equipment is serviced and maintained. The AQAA states that all cleaning materials and chemicals are stored properly and the home adheres to COSHH ( Control of substances hazardous to health). The AQAA also states that fire drills and equipment testing is up to date and the staff also regularly check the call bell system. The staff attended fire training in the last two weeks. Marlborough House Nursing Home DS0000012228.V367570.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 3 3 3 X 3 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 3 18 3 3 X X 3 X 3 X 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 3 X 3 Marlborough House Nursing Home DS0000012228.V367570.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 Marlborough House Nursing Home DS0000012228.V367570.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 Marlborough House Nursing Home DS0000012228.V367570.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. 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!