Inspection on 31/03/08 for St Marks Court

This inspection was carried out on 31st March 2008.

CSCI found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Marks Court 15/01/10

St Marks Court 09/12/08

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE St Marks Court 71 Split Crow Road Deckham Gateshead Tyne and Wear NE8 3TX Lead Inspector Irene Bowater Key Unannounced Inspection 31 March 2008 09:00 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 Marks Court DS0000070970.V361144.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 Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Marks Court Address 71 Split Crow Road Deckham Gateshead Tyne and Wear NE8 3TX 0191 4901192 0191 4901797 stmarkscourt@schealthcare.co.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) Southern Cross BC OpCo Ltd Deborah Maria Douglas Care Home 60 Category(ies) of Dementia (20), Old age, not falling within any registration, with number other category (60) of places St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing, Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 60 2. Dementia, Code DE, maximum number of places 20 The maximum number of service users who can be accommodated is: 60 7 August 2007 Date of last inspection Brief Description of the Service: St Mark’s Court is a purpose built detached care home standing in its own grounds and registered to provide personal and nursing care. This can include offering care to people who have a diagnosed dementia or mental health as well as a physical disability. It is located in the Deckham area of Gateshead and is close to a local housing estate and community shopping facilities. It is on a recognised bus route, which offers easy access to the surrounding estates and shopping areas and also to Gateshead town centre and Newcastle city centre. The accommodation consists of 60 single bedrooms all with their own en suite toilet facility. Accommodation is spread out over three floors and a passenger lift offers easy access to all floors. There is a variety of living space throughout the home with six lounges and three dining rooms. There are bathrooms, showers and toilets on each floor. All are easily accessible. The ground floor is occupied by people who have personal care needs, people with assessed nursing needs occupy the first floor and the second floor is St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 5 currently used for people who have a diagnosed dementia or mental health illness. The fee rates range from £348 up to £535. This includes the nursing contribution, which is set nationally. St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality for this service is 3 star. This means that the people who use this service experience excellent quality outcomes. Before the visit: We looked at: • Information we have received since the last visit on 7 August 2007.How the service dealt with any complaints and concerns since the last visit • Any changes to how the home is run • The provider’s view of how well they care for people • The views of people who use the service and their relatives, staff and other professionals. The Visit: An unannounced visit was made on date 31 March 2008 During the visit we: • Talked with people who use the service, relatives, staff, the manager and visitors • Looked at information about the people who use the service and how well their needs are met • Looked at other records which must be kept • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for • Looked around the building to make sure it was clean, safe and comfortable • Checked what improvements had been made since the last visit • We told the manager what we found. What the service does well: The staff collects information together about the person before anyone moves into the home to make sure they can meet their needs. Staff involve the residents, their representatives and other professionals in the care planning which makes sure their needs can be met. Care plans clear and up to date regarding peoples health, social and personal care needs. St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 7 Medication records are clear and up to date. Staff have formed good relationships with the residents and make sure their rights to privacy and dignity are met. They work hard to promote residents independence at all times. The meals are nutritious, nicely presented and choices are available. Visitors are made welcome and there are good links with the local community. Clear information is available should anyone have a concern or complaint about the care or service they are receiving. The activities organisers work hard to provide activities inside and outside of the home. Staff training is good with over 84 of staff having achieved NVQ level 2 or 3 Staff also complete specialist training so that peoples individual needs can be met. The home has a good standard of decoration and furnishings. All bedrooms are a good size and all have their own private en-suite toilet. Lounges are comfortable, warm, bright and cheerful. Bathrooms are also well decorated and warm. The registered manager makes sure that all checks and clearances are received before staff are employed. The staff have worked together for some time and have formed a stable staff team. People who use the service and their relatives are able to say what they think about how the home is run which helps them to have control over their lives. The registered persons make sure that the home is a safe place for visitors and those who live there. Comments from surveys include: “Our educational programmes are offered and there is a good uptake” “Although my experience of the service is limited to a specific group of people the staff support them in their preferred place of care and choices at the end of their lives.” “My family and myself fee we have a personal relationship with most members of the staff and are very comfortable that we receive all the information we need.” St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 8 “On some occasions X has needed to hear my voice and the staff have made sure I was contacted.” “As I am a frequent visitor to the home I have never had to question the staffs attitude to the residents”. “I can say X is in a five star care home. I am satisfied they her individual needs are met and her opinions and concerns recognised.” “The home is lovely and I get good food” “The staff are kind, they can’t do enough for me” “I am looked after well” “Good food plenty of it” “It’s really lovely living here, caring lovely staff”. “Meals are nice and it is lovely and clean.” 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. St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 9 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 Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 10 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 Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. People are given detailed information about the home and receive full and comprehensive assessments of need to help them make the right decision about using the service. EVIDENCE: The home sets out the aims and objectives of the service in a Statement of Purpose, which is readily available. There is also a Service User Guide that sets out the values of the home. This makes references to supporting the diversity of needs, cultures, and beliefs of all those involved in the home. St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 12 Before anyone is admitted to the home a full needs assessment is undertaken by a Care Manager and the Home Manager. The pre-admission assessments were detailed providing information about peoples personal care, life history’s preferred routines, social activities and cultural needs. This information is then used to complete a plan of care for the individual living in the home. St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10, 11. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care planning, and access to health care services are excellent,demonstrating that peoples’ needs are being fully met. EVIDENCE: Since the last inspection this home has changed ownership. The staff are now busy transferring all of the records including care plans to the new documentation. Care plans were clearly set out and up to date. Accredited assessments tools for the prevention of pressure sore and wound care, moving and assisting, catheter care, continence promotion, nutrition and mental health status were completed reviewed and updated monthly. St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 14 Care plans are regularly reviewed and updated according to changes in social, personal and health care needs. Those who have reduced appetite or low weights are regularly weighed and intervention sought from dieticians. Their recommendations are acted upon and the care plans updated as necessary. Up to date information regarding changes in wound care is documented and regular reviews take place with residents’, their relatives and care managers to make sure the home is still meeting their needs. Everyone has access to all NHS facilities to ensure their healthcare needs are met. There are regular visits from GP’s and other health professionals including, dentists, opticians and chiropody services. Appropriate pressure relieving devices are available. Several people have air cell mattresses and cushions to prevent pressure damage. Advice is sought from, psychologists, occupational therapists, tissue viability specialists, speech therapists and continence advisors. Visits from the multi disciplinary team are recorded in individual care plans. The home has comprehensive medication policies and procedures for staff to use. The delivery of medication has improved.The staff who administer medicine wear a red tabard and can not be approached unless it is an emergency. Records are in place for all medicines received, administered and disposed of. An audit of Controlled Drugs and the Medicine Administration Records (M.A.R.) showed no discrepancies. There is a register of staff who are authorised to administer medication. There were no extra stocks and the medicine trolley was clean and tidy. The fridge was clean and temperatures were recorded. None of the residents in the home self medicates. People living in the home are treated with respect by staff that know them well. The atmosphere was relaxed and friendly and staff supported those who needed help in a sensitive respectful manner. Care plans record wishes about dying and the arrangements they want after death. Families, Palliative care specialist nurses and consultants are also involved in the process. Information about pain control is available and the Medication Administration Records and Controlled Drug records show that staff make sure that appropriate pain relief is given when a person needs it. St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Opportunities to take part in meaningful activities and keep control of everyday decisions are excellent. And people are given the opportunity to lead full and active lives. EVIDENCE: The home has two designated activity organisers. Regular meetings take place to discuss how activities are to be developed. There is an activities programme available and this is displayed within the home. Events include coffee mornings, board games, music, exercises, bingo, in house entertainment and events held out of the home. Photo albums of events and activities enjoyed are available. The home also produces a monthly newsletter, which is readily available in the home. St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 16 People who have dementia or complex health care needs have either small group activities or one to one time with staff. This makes sure their social needs are met and they are not isolated in their own room. Various church services are held and residents are able to choose to attend. The home has developed links with the local Jewish community and staff has had some training so that they have an understanding of their cultural and spiritual needs. There are dining rooms on each unit. The rooms are spacious, well laid out and furnished to a high standard. Each unit has a small kitchen area where staff can prepare drinks and snacks for residents and visitors can make tea and coffee as they wish. Tables were nicely set with tablecloths, cloth napkins, appropriate cutlery and crockery. All of the tables had a small central display of fresh flowers. The chef has asked those who live in the home about their favourite food and copies are displayed. The menus are to be changed as the new owners have consulted with dieticians and have produced a varied menu, which makes sure individual preferences, and dietary needs are met. The staff are to receive training before this service is introduced. The home operates a four-week seasonal menu with choices and other alternatives available for each meal. People choose what they want for the day in the mornings but can change their mind at the point of service. Fortified drinks, high calorie snacks, fruit, hot and cold drinks are readily available throughout the day. The meals are prepared in a central kitchen and then sent to each unit in a “hot lock”. Choices for lunch were mince and dumplings or cod fish cakes with potatoes, carrots and swede. Other alternatives, which were asked for and given were assorted sandwiches, baked potatoes with various filling and salad. Dessert choices were rice pudding, yoghurts or ice cream. Hot and cold drinks were readily available at meal times and throughout the rest of the day. Residents who need support were given assistance in a discrete and sensitive manner and lunchtime was a quiet and pleasant time. St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 17 Comments about the food included: “The meals are very good”. “I can always choose what I want to eat” “I love the food” “I have put on some weight, the meals are lovely” St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is Excellent This judgement has been made using available evidence including a visit to this service. Excellent complaints and protection systems are in place. This makes sure that people are able to express any concern and they are protected from harm. EVIDENCE: There is a detailed complaints procedure, which clearly sets out how and to whom to make a complaint. The procedure is available in the Statement of Purpose, Service User Guide and is displayed in the home. The philosophy in the home is to address any concerns straight away and make sure that they are sorted out quickly and to everyone’s satisfaction. The manager has an open door policy and everyone spoken to say that any concerns would be dealt with straight away. Two complaints have been received at home level since the last inspection. One has been resolved and the other is being investigated at home level. Staff have received training in dealing with potential difficult situations and have access to other professionals should they need further advice on how to deal with behaviours that may be challenging. St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 19 Staff are trained in Safeguarding Adults procedures so can recognise abusive situations and would know what to do if they suspected abuse. There is also written information and guidance, as well as policies and procedures available in the home for staff to look at if they need further guidance. There have been no Safeguarding Alerts made to Local Authority or to the Commission. St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and a pleasant, clean and comfortable place for people to live. EVIDENCE: The home is purpose built and set in a residential area. There are three units, which can be accessed by stairs or a passenger lift. All of the communal areas have been decorated and furnished to a high standard. St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 21 The dementia care unit is nicely decorated and furnished. There are now plans to change the colour schemes and provide pictures and signage to help people with memory loss find their own way around the unit. There are bathrooms and toilets on each floor, close to all resident areas. They are easy to use and include specialist baths and showers. There is slight wheelchair damage to the walls in the bathrooms and toilets. All of the bedrooms have an en-suite facility. Bedrooms were clean, decorated and furnished to a good standard. Many of the rooms are highly personalised and reflective of previous lifestyles. Profiling beds are available for those who need nursing care. All rooms have lockable facilities although staff have access in an emergency. The home is very well lit and has good natural light. Heating is located in the ceiling and each room has individual thermostatic control. The laundry is large with soiled and clean areas. Infected linen is dealt with by using specialist bags so that the staff do not have to handle it. Hand washing facilities are readily available and are in every bedroom. The week before the inspection the home had a “Norovirus” an outbreak of sickness and diarrhoea. The staff took appropriate action and followed good infection control procedures .The outbreak cleared within 5 days. All areas were clean, tidy and fresh smelling. The staff have had training in infection control policies and were seen to follow procedures throughout the day. There are sluice disinfectors on each floor. These were locked when not in use. St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staffing levels and systems around recruitment, selection and training of staff are excellent and meet the range of needs of the people using the service and protect them from harm. EVIDENCE: The home provides nursing, dementia care and personal and social care. Since opening there has been little staff turnover and the staff have been keen to develop their skills so that they can deliver a person centred approach to care. There is no use of agency staff. Comments from other professional include: “The staff are motivated to learn” “Our educational programmes are offered and there is a good uptake of places”. The manager has increased the staffing levels in the home. St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 23 There are two qualified nurses during the day and one overnight. During the day there are nine or ten carers, two of which are senior staff. Overnight there are six carers. There are also domestic staff, administrator, housekeeper, laundry staff, chef, kitchen assistants, maintenance staff and two activities staff. The manager is supernumerary and a deputy manager is also employed. The manager is aware that some people have complex nursing needs and require a high level of direct nursing care. Should this occur the staffing levels are changed so that individual needs can be met. The home has over 84 of staff with NVQ level 2 qualification. Eighteen staff have completed level 3 and thirteen have level 2 Six carers are waiting to start the training. Several are now considering starting level 4. The procedures for recruitment were being followed. There was evidence of Criminal Record Bureau checks, Safeguarding Adult checks, two written references, proof of identity, professional identity numbers for registered nurses and completed induction programmes. Staff have a training and development file. These files also contain supervision and appraisal records. Mandatory training includes, food hygiene, first aid, health and safety, moving and handling, fire prevention. Domestic staff have completed NVQ level 2 in housekeeping and the activities organisers are completing NVQ in activities. Specialist training includes, safe handling of medicines, dementia care, catheter care, use of the syringe driver, wound care, infection control, resuscitation, verification of death and enteral feeding. Staff are also involved in the Palliative Care forum and have had training in using the End of Life Care Pathways, The Company have started training the staff in their Policies and Procedures and staff are to start Dementia Care training “Yesterday Today and Tomorrow”. St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is run by an experienced and proficient manager who makes sure that excellent quality assurance and safety systems are in place. This makes sure that people receive a safe quality of care. EVIDENCE: The registered manager is experienced and competent to manage the home. She continues to update her knowledge to continually improve the service for the people who live in the home. St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 25 Monthly audits of all care and other services are carried out with action and outcomes recorded. The operational manager visits on a monthly basis and completes a separate report. These reports make sure the quality of the home is continually monitored. Records of staff, relative and resident meetings are available. The manager also sets aside time so that anyone can come and discuss any issues or concerns they may have. Staff said that the manager is readily available and always on the units to see that everything is working well. Two surveys returned by staff also said that the manager did not meet them to discuss their role. These comments were passed to the manager for her to look into. Since the last inspection people’s moneys are now kept in a non-interest baring account. The records are clear and it is possible to cross reference withdrawals and deposits with the receipts. Two signatures are available for all transactions. Consideration should be given to helping people open their own account so that they can receive interest on their own money. The manager regularly checks the account and it is audited on a yearly basis. Staff have had training in safe working practices with records kept. Fire training is completed every three months for night staff and six months for day staff. A fire risk assessment is available and up to date. Accidents are clearly recorded and the manager completes monthly accident analysis to examine and track any trends. Risk assessments for the safe use of bedrails are available and up to date. In house health and safety checks are carried out weekly. Water temperatures are recorded to ensure temperatures of 44 C is not exceeded. External service contracts were available and up to date. St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 3 X 3 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 3 X 3 X 3 X X 3 St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Marks Court DS0000070970.V361144.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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