Inspection on 15/09/06 for St Luke`s Care Home

This inspection was carried out on 15th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Luke`s Care Home 04/09/07

St Luke`s Care Home 15/02/06

St Luke`s Care Home 20/07/05

St Luke`s Care Home 02/03/05

Similar services:

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Snydale Care Home

Hawkhills

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The Grove Waltham

Staveley Birk Leas Nursing Home

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

CARE HOMES FOR OLDER PEOPLE St Luke`s Care Home Upper Carr Lane Calverley Leeds Yorkshire LS28 5PL Lead Inspector Karen Westhead Key Unannounced Inspection 09:40 15 September 2006 th 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 Luke`s Care Home DS0000062254.V308546.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 Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Luke`s Care Home Address Upper Carr Lane Calverley Leeds Yorkshire LS28 5PL 0113 2563547 0113 2560275 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) Eldercare (Halifax) Ltd Mrs Sharon Patricia Dixon Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34), Physical disability (4), Physical disability of places over 65 years of age (34), Terminally ill (4), Terminally ill over 65 years of age (4) St Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2006 Brief Description of the Service: St Lukes is a modern, purpose built nursing home situated in a residential area of Calverley. The home is within walking distance of a major road to both Bradford and Leeds, and local bus routes. Accommodation is provided in a combination of twenty-two single and six double rooms. All of the single rooms have en-suite facilities. Residents have a choice of two sitting areas, one of which is used by residents who smoke. The main sitting room is also used for dining. The home is built on one level; therefore there is no need for a passenger lift. There is a car park to the front of the building, and there is level access to very attractive gardens at the rear of the home. The minimum fee is currently £468 rising to £580 depending on the needs of the resident. Additional charges are made for hairdressing, newspapers, selected toiletries or private chiropody treatment. This information was provided to the Commission for Social Care Inspection (CSCI) in August 2006. St Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been quality rated. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between 1st April 2006 and 1st July 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All of the core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by residents. Each of the outcomes are judged using four categories: ‘excellent’, ‘good’, ‘adequate’ and ‘poor’. The judgements are recorded in the body of this report. More detailed information is available on our website – www.csci.org.uk On occasions it may be necessary to carry out additional site visits, some visits may focus on a specific area e.g. medication, food or care practices and are known as random inspections. This visit was unannounced and was carried out by one inspector, starting at 9.40am and finishing late afternoon. The person in charge of the home was the manager, Mrs Sharon Dixon, to whom feedback on the findings of the inspection was given at the end of the visit. This report reflects the preferences of the people living at St Lukes to be collectively referred to as residents instead of service users. The purpose of the inspection was to ensure the home was operating and being managed for the benefit and well being of the residents and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at the completed preinspection questionnaire, the number of reported incidents and accidents, the action plan submitted following the previous inspection and reports from other agencies such as the fire safety officer’s report. This information was used to plan the inspection visit. A number of documents were inspected during the visit; some areas of the home were seen, such as bedrooms and communal areas. The inspector also spent time talking to residents, staff and visitors. Residents who were unable to comment on their experiences were observed. Where appropriate issues relating to the cultural and diverse needs of residents and staff were considered. St Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 6 CSCI comment cards and post-paid envelopes were left, to be distributed to residents and their relatives. After completion these are returned to the CSCI. At the time of writing this report thirteen responses had been received from visitors and three from residents. Their views are contained throughout this report. Overall, visitors were satisfied with the care provided some of their comments included: • St Lukes ‘tries to cater for my relatives needs very well’, • My relative ‘loves the meals, she has always enjoyed her food. The meals look very appetising and they are always attractively served. Good variety and plenty of veg.’ • ‘St Lukes is brilliant. It is unfortunate that not all care homes create this atmosphere of care, welcoming, openness and friendliness.’ • ‘All of the staff have been very friendly, polite’ and answer all our questions. • ‘Although a busy hive of activity, the staff always seem to find the time to break from their busy schedules to address residents needs.’ One relative stated that one resident was sometimes kept waiting when wanting to use the toilet. Residents comments were also positive, some of their comments were: • ‘When I asked to see a doctor he was sent for at once.’ • ‘The home smells clean and fresh.’ • ‘There is a choice of meals and during my stay I have thoroughly enjoyed my meals.’ One comment from a resident was about the loudness of some of the televisions in other residents’ bedrooms. The resident fully understood the issues with deafness and realises there may not be an easy solution to this problem. What the service does well: St Lukes is a clean, comfortable and homely environment to live. The atmosphere on the day of the visit was calm, warm and welcoming. Staff were courteous and friendly. Residents’ needs are met in a way that respects their privacy and dignity and they are encouraged to make choices about how they spend their time. Residents were positive about the range of activities available to them. All bedrooms are fitted with a ‘tracking system’, which lets staff move residents around their bedrooms using specialist equipment. All rooms have a specialist nursing bed (profiling bed), which can be used in different positions depending on the needs of the resident using it. Staff were described by residents and visitors in a very positive light. Staff training is given a high profile by the providers. St Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 7 The home provides a good and varied diet for residents. The presentation of food was described as ‘appetising’ and the menu choices seen covered a wide range of dishes. Visitors are made to feel welcome and one relative commented about the support she and her father had received when their relative had been admitted. The home is part of a small group; a service manager visits the home at least once a month, during these visits residents and staff are spoken to and various aspects of the service are audited, the CSCI is provided with a report following these visits. Staff told the inspector that ‘teamwork was good and they were happy working at the home’. The staff said they were well supported by the manager and senior team and enjoyed their work. Staff talked about their colleagues, who had been absent from work due to illness or surgery and that they had had to pull together to give the residents a good standard of care. 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 Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Luke`s Care Home DS0000062254.V308546.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service and because evidence seen showed how the manager provides good quality information to prospective residents and other interested parties. Residents can be sure that the home can meet their needs as there was evidence to show that the majority of residents are assessed before admission to the home. Residents are clear what they can expect to receive from the home and what they are expected to pay for the service as they have contracts setting this out. EVIDENCE: The statement of purpose is included in an information pack together with a resident’s guide and complaints procedure. The information is easy to read and provides prospective residents with an idea about the home and whether it St Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 10 would suit their requirements. It is not provided in large font currently but the manager was confident this could be arranged if requested. All newly admitted residents are given a written contract setting out the terms and conditions of their stay. Where there might be problems of limited understanding this is discussed and agreed with a relative or representative. St Lukes has a robust pre admission assessment procedure and senior staff undertake all assessments. St Luke`s Care Home DS0000062254.V308546.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service and because the evidence seen showed that the personal and health care needs of the residents are met in a way that respects their privacy and dignity. Residents are given their medication as prescribed and they are protected by the homes system for recording, receiving and storing medication. EVIDENCE: The plans of care for three residents were looked at in detail. Since the last inspection there has been a significant improvement in the way information is recorded and a new format has been implemented. All staff providing care now record information as it happens. Senior staff oversee this and countersign the record. The files seen provided a clear and concise record of the delivery of care and information about how each residents needs had been met. St Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 12 Plans of care are now reviewed monthly and any amendments are carried forward from the daily record. There was evidence of input from external agencies, including tissue viability nurses and notes from multidisciplinary meetings to make sure residents were receiving the best possible support and services. Residents who had any specialist needs, for example pressure sores, this was recorded in their notes and an appropriate care plan had been written. The system relating to residents medication was discussed and looked at. The procedure in place is good and safeguards residents. The nurse observed giving medication after lunch was seen to follow the procedures and did this in a competent and efficient manner. She was particularly patient with residents who were reluctant to take their medication. The home employs a care assistant who devotes part of her contracted hours to organising and engaging residents in purposeful activities. This is recorded on the rota and there is a clear divide in the hours allocated to these separate roles. Throughout the day, staff were seen carry out their care tasks in ways that promoted and maintained the principles that residents are individual, adult and an important part of the community within the home. Staff were heard speaking to residents in a dignified and respectful manner and knocked on doors before entering bathrooms, toilets or bedrooms. St Luke`s Care Home DS0000062254.V308546.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome group is good, with food being excellent. This judgement has been made using available evidence including a visit to this service, which showed. That residents are given opportunities to spend their day in a way they wish. There are a range of social activities offered and residents can choose to join in or not. Residents are able to remain involved with families and friends. EVIDENCE: The home has designated hours set aside for social activities. The worker spends time organising trips and entertainment and works with residents in small groups or individually. A record of activities and who has taken part is used to evaluate the uptake and effectiveness of the activity. Other staff join in and will often, they said, take residents out for a walk or organise an activity over and above those scheduled. The ‘September’ programme was displayed in the entrance hall and involved evening events. Residents said they had a choice about when they get up and go to bed and where they wish to spend their day. One resident did raise concerns about the loudness of some other resident’s televisions at night. The resident St Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 14 understood that those who are hard of hearing might need to have the volume turned up but felt this could sometimes disturb those who wanted to rest. Residents have a choice of two sitting areas, one of which is used by residents who smoke. The main sitting room is also used for dining. The areas are separated by a divider. Food provided in the home was spoken about as a definite plus. The food served during the visit was sampled and was hot, well served and tasty. Staff go out of their way to make sure mealtimes are an enjoyable event and capitalise on the social aspects of residents being together. Breakfast is served in bed to all residents, some are up and dressed others prefer to sit up in bed and take their time. The inspector sat in the dining room during the main meal. The home provides an eight-week rolling menu. The main meal, at lunchtime, always includes a starter of soup, two hot choices and either a cold or hot sweet. Other alternatives are provided where requested. The senior staff serve the meal and during the visit up to five carers were also seen in the dining room. Residents needing assistance or prompting to eat were helped by staff who sat beside them throughout their meal. Residents were given choices at each course and given time to relax in between servings. Liquidised meals are plated in the kitchen and the catering staff showed a good understanding of individual residents likes and dislikes. The cook uses a variety of ways to make sure ingredients, that are high in nutritional value, are used in meal preparation. There was evidence that temperature checks and cleaning schedules were up to date. An environmental health officer visited the home in August 2005. No issues regarding food hygiene or cleanliness were highlighted on this inspection. St Luke`s Care Home DS0000062254.V308546.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Residents are safeguarded from potential abuse as all staff showed a good understanding of adult protection and receive regular training and information about issues affecting older people. EVIDENCE: The home displays its complaints procedure and each resident and relative is handed a copy of it on the day of admission. None of the relatives or residents who completed a comment card had had to make a complaint but it was evident that they knew who to talk to if they did have a complaint. Since the last inspection the home had received one complaint via the CSCI office. The complaint was about the pressure area care a resident received whilst staying at the home for a short stay. This was handed to the home to investigated and a full report was provided to the lead inspector detailing the outcome. The complaint was not upheld. The manager did say she liked to think relatives and residents could raise any problems, however small, with her or the staff team in the first instance. She thought things could then be nipped in the bud before they escalate and people become dissatisfied. St Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 16 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, 21, 23, 24, 25 and 26 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and comfortable home. Individual bedrooms were highly personalised and matched the occupant’s tastes. Residents are not able to benefit from suitable bathing facilities as they are not appropriate for their needs. EVIDENCE: The communal areas are well decorated and domestic in style. The manager had bought some new curtains to be hung in the main lounge and was waiting for new curtain poles to be fitted following redecoration. This was due to be done within a couple of days. The entrance hall and corridor had been redecorated since the last inspection. This had given the home a lift and according to residents and staff made the areas ‘a lot lighter and pleasing to the eye.’ St Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 17 Bedroom doors have a lock to increase residents’ rights to privacy. One married couple said staff always knocked on their door before being asked to enter. Keys are available to those residents who are able to make use of them. Of the bedrooms seen, residents had their personal belonging with them. Some said they had been helped to bring cherished items of furniture with them. No unpleasant smells were noted during the visit, and some comment cards said just that, that the home was always clean and fresh. It was evident that two bathrooms in the home are not being used for bathing. There were items of furniture and surplus equipment being stored in these rooms. The baths had not been fitted with suitable equipment to help residents get in and out of the bath and consequently were not used. Staff preferred to use the ‘wet room’, which provided ample space and equipment to attend to the needs of the residents. The provider must make sure any alterations made are in accordance with the regulations and give residents a real choice about how they wish to be bathed and what equipment they require. The home employs a physiotherapist who works with staff to explore ways of meeting residents’ needs within the home. She visits weekly. The garden, with ornamental pond, is used by residents. This area is suitable for wheel chairs and residents commented on how much they enjoyed it. St Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 18 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 and 30 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Residents are protected from potential abuse by the homes recruitment procedures. Their needs are met by appropriate numbers of skilled and trained staff. EVIDENCE: Some of the staff working at the home have done so in excess of seventeen years. The permanent staff team are a very committed and motivated group. There has been a significant amount of sickness absence due to serious illness/surgery or complications of conditions, which have affected six staff in total. The staff team have been able to address this in a consistent and committed way. The overall feeling was one of teamwork and despite the shortfall in hours staff have been flexible enough in their working patterns to change at short notice. This came across very strongly whilst talking to staff about their work. As it happens there are no staff vacancies at present. Since the last inspection seventeen staff have left the home. The reasons for this varied from those who wanted more money, were offered other work, injury whilst on holiday or were dismissed. The three workers who were dismissed were not subject to disciplinary procedures. St Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 19 The rosters were reviewed and were satisfactory for the levels of dependency. On the day of the visit, staff were seen carrying out their duties in a calm and friendly manner. Three members of staff said they had had a ‘handover’ at the start of their shift and knew what they needed to do. They knew how each resident was and what appointments were booked for the forthcoming shift. The manager was seen taking an active role in the day. She interacted with staff and residents throughout the visit. Over 50 of the work force have completed their National Vocational Qualification (NVQ) award. The files of three members of staff were seen, including a new starter. All the required checks had been done. Copies of interview notes and application forms were available. PIN numbers for the qualified nursing staff are kept up to date. The home employs an administrator who plays a key role within the home and supports the manager in her job. They work well together and spoke frankly about their work. All new staff are linked to a mentor who takes them through an initial induction before they are able to work on shift. Staff confirmed they had been given a code of practice booklet when they started working in the home. Some of these were seen on file. St Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 20 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): 31, 33, 35, 36 and 38 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Residents’ financial interests are safeguarded. The health and safety of residents is taken into account by the practices in the home. EVIDENCE: The registered manager, Sharon Dixon, has worked at St Lukes for 19 years and is committed to making sure the home runs well. She is a registered nurse and has vast experience in the caring sector. The management approach encourages residents and their relatives to be involved in the day-today running of the home. St Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 21 There was evidence to confirm that only one resident has a small amount of cash, provided by their relative, which the home keeps and uses on the residents behalf. All transactions are recorded and accounted for. Other residents either take care of their own arrangements or have a third party, who deals with this for them. Staff said they received regular supervision where they can discuss care practices and their personal training needs with a senior member of staff. The providers carry out a monthly visit to the home and write a report about the matters discussed and any issues, which need attention. They provide a copy to the CSCI for information. Written information about health and safety checks were up to date. St Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 22 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 3 X 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 St Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 23 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 OP21 Regulation 23(2)(j) Requirement The registered provider must make sure there are sufficient baths and showers fitted with a hot and cold water supply for residents to use. Assisted toilets and baths must be installed which are capable of meeting the assessed needs of residents. Timescale for action 19/12/06 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 Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 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 Luke`s Care Home DS0000062254.V308546.R01.S.doc Version 5.2 Page 25 - 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. 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