Inspection on 23/02/07 for St Joseph`s Hospice

This inspection was carried out on 23rd February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

St Joseph`s Hospice 14/01/10

St Joseph`s Hospice 22/02/06

St Joseph`s Hospice 29/09/05

St Joseph`s Hospice 11/02/05

St Joseph`s Hospice 06/05/04

St Joseph`s Hospice 25/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE St Joseph`s Hospice Ince Road Thornton Liverpool Merseyside L23 4UE Lead Inspector Mrs Trish Thomas/Lorraine Farrar Key Unannounced Inspection 10:00 23rd February 2007 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 Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Joseph`s Hospice Address Ince Road Thornton Liverpool Merseyside L23 4UE 0151 924 3812 0151 931 5727 jacintacannon@jospice.org.uk 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) St Joseph`s Hospice Association Miss Jacinta Ann Cannon Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (12), Physical disability (3), Terminally ill (10) of places St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users to include up to 12 OP and up to 10 TI and up to 3 PD. The service should employ a suitably qualified and experienced Manager who is registered with CSCI. Service users in the category TI must be in the age range of 19 years and above. 22/02/06 Date of last inspection Brief Description of the Service: St. Joseph’s is a care home, with nursing, for 25 Service Users. The home is owned by St. Joseph’s Hospice Association (Jospice International) and the manager is Mrs. Miss Jacinta Cannon. The home is registered in the following categories, 12 Elderly, 3 Physical Disability, 10 Terminal Illness. The home was founded within a Catholic ethos and this is reflected in the character of both the interior and grounds of St. Joseph’s. There are two chapels on site, one is integral to the main building and the second is adjacent and can be easily accessed. St. Joseph’s is not exclusive to those of the Catholic faith and all denominations and non-believers are eligible for admission, subject to nursing assessment, and their wishes are respected. The service is provided in two buildings, The Academy and San Jose, which provide a variety of lounge and sitting areas, dining room and conservatory. Both single and double bedrooms are provided and 8 bedrooms have en-suite facilities. There are extensive and beautiful grounds consisting of woodland, gardens and car parking facilities. The grounds sustain a variety of wildlife and are accessible and enjoyed by residents of the home and their visitors where seating is placed for their convenience. The home is situated on a main bus route between Southport and Liverpool with the busy shopping centre of Crosby a five-minute car journey away. St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was carried out by two inspectors over one day. The methods used during the visit were, discussion with the residents, visitors and staff and touring the premises and grounds. Records compiled in the home relating to health and personal care and support, staffing and health & safety were read. What the service does well: What has improved since the last inspection? A record is maintained of social activities on offer to residents and the recommendation from the last inspection (Standard 12), has been met. Medication records were satisfactory during this visit and the requirement from the last visit (Regulation 13), has been met. St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 6 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. St Joseph`s Hospice DS0000017272.V295401.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 St Joseph`s Hospice DS0000017272.V295401.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): Quality in this outcome area is good. Prospective residents have their needs assessed before moving in to the home and all have a contract of residence/statement of terms and conditions. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 2,3. The home does not provide intermediate care and is not assessed against standard 6. All residents have a contract of residence/statement of terms and conditions, which clearly states the fees (and who will meet them), additional services not covered by the fee, room to be occupied and terms and conditions of occupancy, including notice periods. The home’s brochure states : “Patients are referred to us from many sources, but admitted only after thorough multi-disciplinary assessment, except in emergencies.” From reading care files and in discussion with the manager and staff the following evidence was obtained. All residents whose files were read, had been admitted on the basis of a full assessment of need, carried out by St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 9 people trained to do so. This is supported by ongoing assessment by staff in the home, which addresses health/personal care, cultural and social preferences, and forms the basis of the individual’s care plan. Copies of assessments are held on individual care files and the assessments for four residents were read. Assessed needs were tracked in care plans and there were action plans in place to meet the identified needs for each individual. St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. Residents receive support in the way they prefer, which is in accordance with their needs, beliefs and aspirations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 7,8,9,10,11. There were care plans in place for all residents and a sample of four were tracked (two by each inspector). Care plans are regularly updated and provide the relevant information to support each resident’s health and personal care. For example: Arrival notes were clear for a resident who was at risk of pressure sores. There were records as follows: ‘pressure sores dressed / mattress put on bed’ Residents’ personal preferences were recorded in detail. For example, “Curtains to remain open in the night, does not like the door shut”. St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 11 A number of visitors were in the home during the inspection and some comments they made are as follows: “I am overcome with the care and attention. I feel like I have come home”. “Staff answer the buzzer quickly, they talk to (resident) when providing personal care and explain what they are doing.” (Resident), said that staff are following preferences stated in the care plan, such as leaving the curtains open at night. The home’s brochure states arrangements for health care for terminally ill residents in partnership with relevant agencies, such as doctors, Macmillan Nurses and social workers. “We in turn draw on those specialist services to support our patients.” The following evidence gained through discussion with residents’ visitors, staff and a G.P. and by reading care files, supports the statement in the home’s brochure. Two general practitioners are designated to Jospice, one being from a local surgery and one from Primary Care Trust. There are routine GP visits on weekdays and telephone access during weekends. A multi disciplinary meeting is held each Wednesday with a GP attending, also Macmillan Nurses and nurses employed by Jospice, to discuss residents’ care. There are also regular update meetings. There is further support from the local Consultant in palliative care medicine who provides professional advice as needed. In commenting on care and support, the daughter of a resident said, “They are here almost before you call (resident) feels safe and comfortable in the home. They call up the GP immediately if needed”. Residents said they are able to retain their usual G.P. if in the area, on admission to Jospice, and they have a named nurse who takes a personal interest in their care and support. Soon after moving in, residents had received a medical check-up and medication review carried out by a G.P. Arrangements for medication were discussed with a team leader and the storage area was visited. The member of staff who was spoken with said she did medication courses a few years ago and has had updates recently and training on syringe drivers. Medication Administration Records are written up by the G.P. and signed by staff as medication is administered. Records and storage of medication, including Controlled Drugs were checked for two residents and were satisfactory. Returns are securely stored and audited weekly. Residents who wish to self-medicate are advised to inform a Team Leader (who is a member of nursing staff), and fitness to self-medicate is determined subject to risk assessment. Otherwise, prescribed medication is administered to residents by a nurse. St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 12 The Vision and Values stated in the home’s brochure are as follows : “Profound respect for the autonomy and dignity of every individual in our care, and a determination to sustain them to the end of their lives.” Evidence to support this statement was obtained through the comments of residents and their relatives and by direct observation. A visitor said “ (Resident) used to come here as a visitor, when he moved in himself, he said it was as he had thought. ‘The care and support are second to none, you couldn’t find better. What you see as an outsider is as it is’.” A care assistant who was spoken with was able to explain care needs of residents, saying that there is no daily routine and the home life is based on what residents want. Another care assistant said that is different from her last job as she has time to spend with residents and that there is no routine, Nursing staff have told her that it is about what each resident wants on that day. Jospice Mission Statement says, “The emphasis here at St. Josephs is to try and provide a caring environment with as homely an atmosphere as possible. We are here to meet your needs, not for you to fit into our routine.” Inspectors were aware of a pleasant atmosphere in all areas of the home and staff did not appear to be rushed. Residents looked well care for and were maintaining their mobility and independence, and/or receiving high levels of support as needed. Jospice specialises in caring for terminally ill people and for those who have long-term degenerative or disabling conditions. The care is aimed at meeting the individual needs of those who do not need hospital care but who cannot be care for adequately in the community. There is also a respite care service to help people who are terminally ill and their families/carers. Jospice employs a Family Support Nurse who is trained in bereavement counselling. Her role is to provide support to individual residents who are terminally ill, and to their relatives. This service is provided at the discretion of each individual resident and/or family member. St Joseph`s Hospice DS0000017272.V295401.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): Quality in this outcome area is good. The lifestyle in the home was meeting residents’ expectations and preferences and their diversity is respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 12,13,1,4,15. Residents and their visitors were spoken with and care plan daily activities records were read. A resident who moved in recently and a relative spoke with an inspector, “The food is very good, you get lots of cups of tea’ they said that visitors may call in when they want to. “On the first day here, (visitor was here they made her a meal and showed her the kitchen. She can make a cup of tea whenever she comes to see me”. A visitor said, “Staff are very good, help (resident) to get ready if he is going out.” Another relative said she can visit when she wants though staff ask that visits be arranged for after 11.30am., if possible, as people are getting up. She helps her relative (who is a resident) in the dining room with the meal, and they go out for a walk in the grounds together. St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 14 A resident described the home as, “Very impressive,” and said meals are good and visitors can come at any time. I feel at home, and can have a drink whenever I want. They also leave a jug of water by my chair.” Care plans contain daily events records, an example as follows : “February Activity Log records, watching films / chatting in lounge / TV. Complimentary therapies – weekly massage with oils.” The activity file contains reflection of complementary therapies – and gives evidence these are altered to suit each individual and their feelings. For example one record states, “Insecurity, nightmares – fear of dying – reassurance given, used oils to slow anxiety calm and sooth.” Activities Diaries state: “Tuesday – bingo / Wednesday – chiropody & film and video / Thursday – Art & Crafts / Friday – Reminiscence / Sunday – Old Time Music”. Also monthly activities which are displayed, celebrated Valentines Day and had plans for St David’s Day /St Patrick’s Day / Mothers day, with families invited. There was a pianist playing in the dining room over lunchtime in San Jose and volunteer plans are arranged to support individuals once or twice a week as preferred. Staff who were spoken with, said that a hairdresser visits the home every week and residents have access to a range of therapeutic and paramedical services such as physiotherapy, opticians, chiropody, advocacy and aromatherapy. Recognition of residents’ privacy, dignity and culture were seen to be recognised in information provided to them and in medical/care records compiled in the home. The home’s brochure states, “The inspiration which founded our hospices was rooted in the Catholic faith, and that is still important to us. We welcome residents and staff of any faith or of none.” The Catholic origins of Jospice are evident in the grounds and communal areas, where religious statues, pictures and symbols are in evidence. Residents who are not of the Catholic faith may have their bedrooms decorated to their own belief and have holy pictures/statues removed on request. Ministers of all denominations are welcome to visit the home to support residents and use the chapel. One such minister, who was visiting to arrange a service, was spoken with. There is also a chaplain from a local Catholic church who visits regularly to say Mass and administer sacraments. Residents’ care files which were read, contained records of their lifestyles and preferences. The comments of visitors confirmed that residents choose when St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 15 and how care is given, (within reason), and there is flexibility in the home’s staffing and routines to accommodate their wishes and feelings. Residents who commented said the food is, “Very good,” “Lovely”, “Well cooked.” A sample of menus showed variety and choice. The recently appointed cook said that there are regular deliveries of fresh meat, fruit and vegetables. Conditions in the kitchen were very good, food storage was satisfactory and the kitchen and appliances were very clean. St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. There is a robust complaints procedure which is followed but staff need instruction in POVA procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 16,18. The home has a complaints procedure and a copy is given to residents and their representatives as they move in to the home, as confirmed by residents who were spoken with. A record of complaints and outcomes is kept in the home. Staff receive training in protection of vulnerable adults and the vetting and recruitment procedures, in appointing staff, are aimed at protecting residents. There was an outstanding adult protection investigation at the time of this inspection. A requirement is given under Regulation 13, that staff are provided with updates in Local Authority POVA reporting procedures and evidence management. The manager, Miss Cannon, informed inspectors that she has recently attended POVA training. St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 17 St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The home is hygienic and mainly in good condition, improvements are necessary in some areas. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 19,26. A resident said his bedroom meets his needs and is always warm. Also, there is a lovely view of the garden. A visitor said the environment, “Could do with some TLC”. A visitor said that (resident’s) room is suitable and (resident) is happy with it. A resident said, “There is a good cleaning routine’ and the bedroom is kept clean.” A member of staff explained that everyone has a daily bed linen change. St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 19 Further evidence was obtained through walking the buildings, discussing cleaning schedules with staff and checking related training. In touring the premises it was observed that some areas appear shabby and in need of redecoration. In San Jose the hall has marked walls and the carpet is threadbare in places with metal rods holding it together, which may cause a tripping hazard. A requirement is made under Regulation 13 (4) that a risk assessment is carried out regarding a potential tripping hazard from the carpet referred to in San Jose. A recommendation is made under Standard 19 that a decoration plan be established for the home, to ensure that good standards are maintained. Two bathrooms were renovated last year, to a high standard with domestic style tiling. One toilet for service users is in the sluice room. One bathroom has stained bath. There is an adapted shower available. The dining room in San Jose is bright and clean with tables nicely laid and area for relatives to make a drink, and the lounge has been recently decorated. There is a lounge/dining room in the Academy was seen to be well used by residents and their visitors during the day. There are good cleaning routines in the home and standards of hygiene are very good. There are systems in place for infection control, there being colour coded laundry bags, and protective gloves and aprons are provided for staff. There are designated cooking, laundry and cleaning staff and training is provided in MRSA procedures, health & safety and infection control. The laundry and kitchen were in good order, hygienic and well equipped. Cleaning schedules were signed for week 19/2/07 and there is a current clinical waste contract in place St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents’ needs are met by the numbers and skills of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 27,28,29,30. Staff rosters gave evidence of numbers and skill mix of care assistants and nursing staff with good ancillary support levels in cooking, cleaning, administration and general maintenance. A sample of staff files was seen and there was evidence of police clearances, two references and proof of identity. Staff are issued with Person Specifications, Job Descriptions and Contracts of employment and have received induction training on appointment. For nursing staff, PIN numbers were up to date for the sample which was checked. All staff receive a range of training which is in keeping with their roles and responsibilities. 72 of care staff had NVQ qualifications (2/3) at the time of this visit. A visitor was asked about staff conduct and competence, “We trust them (resident) gets very good care” St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 21 “They respond very quickly (to buzzer). When two staff are helping me, they talk to me and not to each other. They are very good”. A visitor described staff as, “ A wonderful team” and, “They come almost before they are asked” and “They are impressive.” St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The home is well run in the best interests of residents’ comfort, welfare and safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is Ms. Jacinta Cannon, who is a qualified manager and who has an open and inclusive management style. The service is managed in two sites and Team Leaders supervise care and nursing staff in both buildings. The manager encourages innovation amongst staff, and career development through appraisals and training programmes. Staff have input into the running of the home, for example, three members of nursing staff are currently reviewing the home’s policies in line with equality and diversity. A member of St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 23 staff who commented said she attends regular staff meetings and feels everyone’s views are listened to. “They appreciate you and tell you if you are doing something wrong.” “I think there is a good working relationship amongst staff they are encouraged to discuss issues.” “I am confident that the nurses would act on anything which was reported to them.” Quality audits are based on seeking the views of those who use the service and Jospice has recently been awarded a five star rating. Records of the process and outcomes are held on the premises. The manager said that residents have control of their own money and fees and charges for extras are clearly stated in Contracts of Residence. The relative of a resident confirmed this to be a fact. Regular Health and Safety and maintenance meetings are held, the last being in January 07. Health and safety checks and certificates were up to date. The home maintains records of accidents to residents and staff, which were seen. Lift certificate 30/10/06, Annual Landlords Gas certificate 2/3/06, Electrical Certificate (3 or 5 yearly) 23/11/06, Boilers Feb 07, Portable appliance tests Oct 06, Moving Equipment 29/12/06 Fire Book : Fire Alarms weekly, Fire drill 1/2/07, Fire extinguishers 3/9/06, Smoke Alarms 23/12/06, Emergency Lighting 25/11/06. St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 24 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 4 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 2 2 X X X X X X 4 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 St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 25 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. 1. Standard OP18 Regulation 13 Requirement The registered person must make arrangements by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. To ensure that “all parts of the home to which residents have access are so far as reasonably practicable, free from hazards to their safety”, The registered person must : Arrange for a risk assessment to be carried out on the hall carpet in San Jose. Timescale for action 23/05/07 2. OP19 13 01/04/07 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 Good Practice Recommendations DS0000017272.V295401.R01.S.doc Version 5.2 Page 26 St Joseph`s Hospice 1. Standard OP19 The registered person should arrange to be in place, a decoration plan for the building. St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Joseph`s Hospice DS0000017272.V295401.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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