CARE HOMES FOR OLDER PEOPLE
St Joseph`s Albert Road Bognor Regis West Sussex PO21 1NJ Lead Inspector
Mrs G Davis Unannounced Inspection 26th October 2005 09.30 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 Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 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 Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service St Joseph`s Address Albert Road Bognor Regis West Sussex PO21 1NJ 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) 01243 864051 Grace & Compassion Benedictines Sister Mary Breslin Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 28th October 2004 Brief Description of the Service: St Joseph’s is a privately owned Care Home registered to provide accommodation for up to 22 service users in the of category OP (Old Age) The establishment is a large detached house, which has been further extended to provide accommodation on three floors all of which are served by a vertical lift. All rooms are for single occupancy, are of generous proportions and have en-suite facilities. There is an area for car parking to the front and a private and well-tended garden to the rear. Housing to the rear of the property provides additional accommodation for residents’ visitors and a quiet dining room where residents can entertain their relatives and friends. An independent building (the Jubilee Room) has been erected in the garden and this is used a venue for parties and other gatherings and any entertainment or activity being provided. It is also used to house the home’s extensive library of books, DVD’s and CD collection. There are independent catering and toilet facilities adjacent. A facility for charging wheelchair batteries is available. Situated in a quiet residential road in Bognor Regis it is approximately half a mile from the town centre and within easy walking distance from the seafront. The registered provider is the Grace and Benedictines (Organisation) and the Registered Manager is Sister Mary Breslin. St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 6 This was the first of the two inspections (minimum) that an inspector must make in a year. On this occasion this inspection was unannounced and took place over one day in October 2005. The aim of this inspection was to find out how the home cared for the residents and their opinions as to how well the home did this. A tour of the home was undertaken and the establishment was found to have accommodation that exceeded the minimum standard. All of the bedrooms had en-suite bathrooms; some fitted with showers and others with baths, which had been equipped with appropriate aids to enable the occupant maximum amount of independence possible. Most were of very generous proportions. The décor and fabric of the home was attractive and well maintained and the building offered a variety of areas for residents to sit and relax in. There was a high standard of cleanliness throughout the home. During the course of the inspection the inspector met with members of the care team including external contractors and also spoke to a number of residents to gain a sense of what it was like to work or be a resident at St Josephs. The overall quality of care provided was excellent and all the residents spoken to expressed total satisfaction with the care they received and in particular were very complimentary regarding the staff team and registered manager. “ Sister Mary and staff are lovely and I can have a joke” “ Sister Mary’s wonderful, she has everything under control – nothing is impossible”. The observed practice was sensitive and appropriate. A meal was sampled and eaten with the residents in the dining room. This was found to be cooked perfectly, was well presented, very appetising to smell and enjoyable to eat. The dining room was comfortable and attractive and the atmosphere relaxed and friendly. The care staff members were supportive and unobtrusive while carrying out their duties. Visiting practitioners commented on how welcome they were made to feel when visiting the home and how happy the residents were living at the home. “We work in a wide range of settings ------ quite honestly this is extraordinary, there’s a sense of community, a real sense of caring-they will walk the extra mile. Over the years we’ve been to scores of homes and this is the best by far.” Another said, “ I would say that the care offered here is the best I’ve ever seen.” The home has achieved the Investors in People Award and International Standard for Quality Policy and Procedures (ISO 9001:2000). The Registered Manager achieved the Care Choices Care Training Excellence Awards Trained Manager of the Year Award 2003. A recent Quality Assurance Audit commissioned by the Manager and carried out by an external consultant has awarded the home five stars for “demonstrating an excellent standard of care”. In addition four crowns were awarded for an “excellent standard of facilities and services” The report also recorded that the home “ demonstrates full accommodation of all wheelchair user needs” On the day of inspection there was a high staffing level enabling a number of individual residents the opportunity to go into Bognor to shop. There have been no complaints made to the Commission for Social Care Inspection regarding the home. There were no requirements or recommendations arising from this inspection.
St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 7 What the service does well:
St Josephs is a home where the resident is at the forefront of everything that is carried out. There is a high staffing level with most staff members of the religious community, and this promotes a strong feeling of ‘family’. One person told the inspector “They have been very good to me----you don’t feel alone. All my relatives died in their sixties-the Sisters’ said ‘you’re not alone you’ve got us’ ”. There is also a high level of volunteers and together with the staff group they offer opportunities for residents to continue to enjoy all the facilities of the locality and beyond. Relationships between staff members and residents were shown during the course of the care staffs’ work with the residents, with much laughter and good humour. Careful pre-admission assessment ensures that essential information is obtained for the care plan. Great care is taken to enable the prospective resident to sample all aspects of life in the home prior to admission. The care plans identified the preferences of the residents and it was seen that they were given choice in all that they did and that there were no petty rules to observe, for example they could go to bed and get up at whatever time they wished and staff would be careful to observe their privacy at all times. Along side the written care plan a photographic diary of significant events has been compiled for each person-this acts as an excellent aide memoir for those who have become forgetful. The care plans are reviewed and updated on a monthly basis. There is additional accommodation for residents to use to enable friends and relatives visit and stay if required. There is a thorough and robust recruitment procedure with excellent staff records. Staff members are encouraged to undertake training to further enhance their practice and each member of staff has achieved NVQ level II and above. Excellent policies and procedures provide a safe environment for the residents and guidance for staff members. There are a wide variety of facilities and resources available for residents’ use. A generous staffing level allows for individuals to enjoy one to one stimulation, which includes shopping, cooking and other rehabilitation activities as well as numerous social opportunities. External co-ordinators are employed several times a week and other group activities include something for every interest. There are a wide variety of facilities and resources available for residents use. The general environment is well maintained with attention to cleanliness. The home is generally comfortable for the residents to live in with plenty of space and light. There is excellent personal accommodation as well as communal
St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 8 areas and facilities that provide opportunities to follow new interests or maintain old ones. 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. St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 9 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 Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1. 2. 3.5. All prospective residents, or their representatives, have a number of opportunities to make an informed choice about whether they want to live at St Josephs and have their needs thoroughly assessed prior to admission by a senior member of staff. Those that choose to live at the home have a written contract/statement of terms and conditions with the home that they or their representative has agreed to. Intermediate care is not provided by the home. EVIDENCE: The Service Users Guide and Statement of Purpose has recently been reviewed and copies given to the service users and the Commission for Social Care. The documents have been combined into one single document, which is very easy to access. Copies have been provided on CD Rom and Tape. A service user proofread a version in Braille, which is also available for those who are visually impaired. The statement of terms is contained in the Statement of Purpose / Service User Guide and each service user has a copy. Prior to admission a full assessment of need is recorded on a form, which has been designed specifically for the purpose. The form is comprehensive and includes details of the individual’s personal and financial details, psychological status, likes/dislikes and allergies, medication and general health details. This will
St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 11 include any information obtained through assessment made by other professionals i.e. the Occupational Therapist. Identification of action to be carried out following admission is also included. The inspector was able to evidence that the most recent admission had undergone a thorough preadmission assessment and included a full consultation with the service user. Following an assessment of needs, an analysis is undertaken to ensure that the care home can meet them, a letter regarding the outcome is sent to the prospective service user with an explanation if the outcome is negative. The admission policy is found in the Service Users Guide/Statement of Purpose. Whenever possible a prospective service user will be visited at their home or hospital to be assessed and they and their relatives if appropriate will be invited to make as many visits to the home as required. A trial stay of an indefinite period is invited to ensure that the service user makes an informed decision to stay. St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7. 8. 11. Where possible residents or their relatives/representatives are involved with the drawing up of their care plans, which contain detailed information of how the care and health needs of the residents should be met. From evidence gathered Service Users and their families are treated with care, sensitivity and respect at the time of their death. EVIDENCE: Detailed information from the pre-admission assessment of need is used as a basis to inform the care plan and, with the service user, further areas of need are considered and identified, including a Waterlow pressure sore skin assessment and a nutritional assessment. Risk assessments regarding all areas of potential harm to the resident are undertaken. The inspector was able to evidence that the plan had been drawn up in collaboration with the residents and noted that the plan encompassed the residents’ specific wishes regarding the arrangements to be carried out with regard to their dying and death. In addition a visual diary is compiled for each person. This contains photographic material from their past and a record of all aspects of the activities undertaken as part of their life at the home. The diaries are used in a variety of ways and are a useful tool when carrying out reminiscence or orientation therapies with the resident. From observations
St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 13 made on the day the Inspector concluded that the staff group treated the residents with respect in all aspects of their care. All residents are registered with a General Practitioner of their choice and all other health related needs i.e. dentist, optician etc. are available as required. If the resident is unable to make their own arrangements then a member of staff will provide support and transport as required. Often a visit to the surgery is used as an opportunity to enjoy lunch out. Domiciliary visits are arranged if preferred. The care plans reflect the assessed health care needs and include nutritional assessment. Specialist equipment is provided if required and this includes that which will prevent pressure sores. Keep fit sessions are held twice monthly and residents are encouraged to attend. A close liaison is maintained with the community support systems i.e. community nurses and the local hospice. The establishment has a policy on dying and death, which states clearly the chosen philosophy of the home. Each service user has their wishes on what is to be done in the event of serious illness or death recorded in their care plan, this often includes instructions regarding the arrangements for their funerals and afterwards. There is an open and dignified attitude to death with the care staff providing a warm and comforting support to all. The home has a chapel and most of the service users choose to lie in rest prior to their funeral. The home has accommodation, which relatives are able to use at times of need. St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The residents are provided with the opportunity to follow their chosen lifestyle at all times. Where the resident is unable to make those choices and decisions for themselves, family or representatives are consulted to make sure that the person has as much control over their lives as possible. A wholesome and balanced diet is provided EVIDENCE: Evidence is found in the Service User Guide/Statement of Purpose and care plans that the routines of the establishment are flexible and crafted to suit the individual. Plenty of visual stimulation is available, in particular photos of recent outings and occasions. The enhanced staffing numbers enjoyed makes it possible for outings for individuals or groups to take place on a daily basis. Activities and entertainment is provided on a daily basis and includes song and dance sessions, discussions, poetry appreciation, garden club and videos. In house activities take place in the Jubilee Lounge and on the day of inspection a group of residents were undertaking the re-construction of a 1930’s house under the guidance of a specialist co-ordinator. He informed the inspector that he had been commissioned to promote various activities for up to four times per week. Visits to the theatre and other places of interest take place on a regular basis,
St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 15 going out to a pub for lunch is particularly popular. A number of the residents have been encouraged to learn how to use a computer. The care plans reflect the service users preferences’ regarding likes and dislikes and dietary needs. A large menu is put on display in the hall to inform those who are unable to read the menu board. Individual serving dishes are provided on each table so that service users can help themselves to the food. Each service user was provided with their own linen napkin. The inspector joined the residents at lunchtime and sampled the meal, which was well balanced with a choice of two main dishes, cooked to perfection and delicious. There was enough food provided to allow each person to have a second helping if they wished. A vegetarian alternative was available. The dining room was comfortably and attractively furnished and promoted a congenial atmosphere. The tables were elegantly set and fresh flowers used to decorate them. St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The residents or their representatives are sure that they can trust the home to protect them as far as possible from bad practice and unacceptable behaviour from others. EVIDENCE: The establishment has only received verbal complaints ‘grumbles’, which the inspector found had been recorded. They involved small domestic issues, all of which were appropriately resolved. The home has clear instructions for staff members as to what to do if abuse of a resident is suspected and the members of staff that were spoken to in depth were knowledgeable about the procedure to take and had received training. The recruitment files examined showed that all the checks to ensure proper security screening on all applicants had been carried out. St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19.20.21.23. The home is a comfortable, pleasant and well-maintained building, which is decorated and furnished to a high standard. As well as a choice of communal day space it provides each resident with a room with en-suite facilities that has been furnished to meet their wishes and needs. Regular maintenance makes sure that the environment is safe EVIDENCE: During the course of the inspection the majority of rooms were visited to make sure that the environment was safe and comfortable for people who live there. St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 18 All rooms had en-suite facilities, which contained the required specialist equipment to promote independence. It was seen that many residents had brought personal possessions into the home, including small items of furniture, ornaments and photographs. There are eight separate lounge areas within the home, which provide a variety of options for the service users. A large dining room caters for all of the service users however there are two additional dining rooms available elsewhere on the campus, which provide the service users with a private place to entertain their friends. Both have been fitted with the call bell system. A private chapel also provides somewhere for the service user to use for quiet reflection even if they do not wish to attend the religious services held there. There are private areas in the garden for those who prefer their own company as well as larger areas for a group to utilise, all areas have been provided with comfortable garden furniture. A toilet has been provided for service users to use when in the garden. A call bell has recently been fitted externally. A large pavilion has been erected in the garden. Entitled the Jubilee Room it is used as an entertainment centre utilising a 60” wide screen LCD TV/DVD/Digibox. It is also used for a variety of social occasions including tea dances, birthday celebrations and entertainment groups. A wheelchair store has been provided with a battery charger. A loop system is fitted to the sitting, dining rooms and chapel. A Health and Safety Consultant has been engaged to be responsible for the maintenance of the building, Risk Assessments and the management of an ongoing programme of redecoration and refurbishment. Regular visits in accordance with Regulation 26 (Care Standards Act 2000) monitors that all health and safety checks are undertaken and that the general fabric of the building is satisfactory. There was evidence that the home complies with all health and safety legislation. Risk assessments regarding the safety of the building were in place. St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27.28.29.30 St Josephs has an adequate number of staff members with appropriate training and skills to provide competent care to the residents at all times. EVIDENCE: The home has a very high number of care staff members working each day. These are comprised of a number of ordained nuns and postulants and on average there will be up to twelve members of care staff on duty at any given time apart from nighttime. Others work in the kitchen or on domestic duties. There is a good mix of skills and ages. All staff members’ receive regular in house health and safety training and other service related topics. All members of staff have achieved National Vocational Qualification level II, or above an ongoing and full training programme in a variety of service related subjects have been in place throughout the year. An induction and foundation training programme has been introduced to meet the National Training Organisation workforce training targets. Specific service related in house training is ongoing and a copy of the training dates and subject matter was provided to the inspector. Group and individual supervision is provided. A yearly self-appraisal/appraisal is carried out to evaluate the learning of the previous year and to set targets for the coming year. Two members of staff have achieved NEBOSH cert and manage all Health and Safety issues, five members of staff are trained in First Aid. The Registered Manager has achieved National Vocational Qualification V. There are appropriate recruitment procedures in place and the inspector was
St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 20 able to examine the file of a recently employed staff member. Staff members are given a job description, and security checks are undertaken. All the information required by schedule 2 of the Care Standards Act 2000 was included on the file. Details of the training undertaken and a training profile were included. St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home is run in a manner that offers protection to all aspects of the residents’ interests. EVIDENCE: The Registered Manager has a Registered General Nurse Qualification and has twenty-five years of experience of working in a care home. Twenty of those years have been as a Manager. She has completed the National Vocational Qualification in Care Management levels IV and V. and was awarded the Care Choices Care Training Excellence Awards, Trained Manager of the Year Award in 2003. The manager maintains an ongoing interest in training and intends to add to her management skills and qualifications. In discussion with staff members and residents it would appear that the manager is very open and transparent in her approach to management. In particular all care staff spoken to confirm that they considered that she delegated appropriately and that they all felt included and knowledgeable. A
St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 22 recent independent Quality Assurance Audit identified “ The Manager has excellent leadership skills, a clear vision of the way the home should be delivering care to residents and has introduced systems for delivering high quality care” As a registered charity there are transparent and suitable financial procedures in place, these are open to inspection but not inspected on this occasion. All service users control their own finances with the help of a chosen representative if necessary. Individuals’ money is held separately for each service user and receipts are given. The records were noted to be appropriately managed and up to date. Each service user is supplied with a key to their door or a lockable box to keep private or valuable possessions safe or they can keep them in the homes safe. All health and safety regulations have been complied with. Staff members have regular refresher training sessions in manual handling, first aid, fire safety and safe food handling. Dangerous substances are used and stored appropriately. Reasonable precaution to protect service users from accidental injury has been carried out i.e. window restrictors, thermostatic mixer valves on water outlets and radiator protection where needed. A new nurse call system with individual remote call pendants added has been introduced to ensure that all those who are immobile have access to staff at all times. St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 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 4 4 4 X 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 X 10 X 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 X 4 X X X STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 X X 3 X X 4 St Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? 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 Joseph`s DS0000014734.V262179.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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