Care Home: Thurlston House

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What the care home does well The home is good at assessing if it can meet the needs of residents before they come to the home. Residents said that the activities provided by the home meet their needs. Staff said that they were supported and encouraged to obtain qualifications. One resident said they feel safe and comfortable at the home and their opinions are sought. Residents and staff said they have a good rapport with Mr Hutchings and he runs the home in their best interests. What has improved since the last inspection? Care plans include relevant information and clear guidelines informing staff how to meet the individual resident`s needs. Documentary evidence of staff qualifications is kept in the home. Each staff member has a satisfactory CRB check relevant to their job role and employer. There are adequate means of escape from the laundry room. Bathroom locks enable staff to gain easy access in an emergency and prevent residents from being locked in. End of life planning has been introduced and dementia training has been completed. Residents bedrooms have been redecorated. A new patio area has been created outside the front entrance. Frequency of residents and staff meetings have improved, enabling greater opportunites to be involved in decision making & giving feedback as to how things can be improved. What the care home could do better: Although requirements were not made as a result of this inspection, Mr Hutchings confirmed work is underway to address the following: Two bathrooms need updating with specialist baths to better meet the needs of the residents. Equipment in the main kitchen needs replacing. Reduce the use of agency staff by employing permanent staff. CARE HOMES FOR OLDER PEOPLE Thurlston House Victoria Hill Road Fleet Hants GU51 4LD Lead Inspector Tracey Horne Key Unannounced Inspection 24th October 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Thurlston House DS0000034233.V347481.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. Thurlston House DS0000034233.V347481.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thurlston House Address Victoria Hill Road Fleet Hants GU51 4LD 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) 01252 628520 01252612539 brenda.barney@hants.gov.uk Hampshire County Council Mr Clifford Roy Hutchings Care Home 49 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Thurlston House DS0000034233.V347481.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 only - PC to service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP 2. Dementia - Code DE The maximum number of service users who can be accommodated is 49. 7th November 2006 Date of last inspection Brief Description of the Service: Thurlston House is a large residential care home, managed by Hampshire County Council, which was first officially opened on 26 March 1974. The home is over two floors with all the bedrooms on the ground and first floor. There is a large garden. Thurlston House is situated within a mile of Fleet town centre. Thurlston House is able to offer care for up to forty-nine older persons, in the category OP and up to fifteen service users in the category, DE[E], for those suffering from dementia. The fees for the home range from £403.00-£446.00 per week. Thurlston House DS0000034233.V347481.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards (NMS) and Regulations. The findings of this report are based on several different sources of evidence. These included an unannounced visit to the home, which was carried out on the 24th October 2007 between 09.30 and 14.30, during which the inspector, Mrs Tracey Horne had the opportunity to speak with staff, view records and procedures and talk to the registered manager Mr Hutchings. Observations were made regarding the interaction between residents and staff and the care provided. The people living in the home prefer to be referred to as residents, therefore the rest of this report will reflect this. Mr Hutchings returned the Annual Quality Assurance Assessment (AQAA) prior to this visit and the Commission for Social Care Inspection (CSCI) sent surveys to residents, relatives. Staff and a healthcare professional. The findings of the surveys are included in this report. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the CSCI. What the service does well: What has improved since the last inspection? Care plans include relevant information and clear guidelines informing staff how to meet the individual resident’s needs. Documentary evidence of staff qualifications is kept in the home. Thurlston House DS0000034233.V347481.R01.S.doc Version 5.2 Page 6 Each staff member has a satisfactory CRB check relevant to their job role and employer. There are adequate means of escape from the laundry room. Bathroom locks enable staff to gain easy access in an emergency and prevent residents from being locked in. End of life planning has been introduced and dementia training has been completed. Residents bedrooms have been redecorated. A new patio area has been created outside the front entrance. Frequency of residents and staff meetings have improved, enabling greater opportunites to be involved in decision making & giving feedback as to how things can be improved. 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. Thurlston House DS0000034233.V347481.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 Thurlston House DS0000034233.V347481.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): 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives have the information needed to choose the home that will meet their needs and have their needs assessed prior to receiving residential or respite care. EVIDENCE: Mr Hutchings completed the AQAA that states that prospective residents and their relatives are encouraged to make informal visits to the home. For non emergency admissions, prospective residents are invited to spend the day at the home that enables an initial assessment to be completed, or alternatively a visit will be made to the person to make the assessment. Each individual is offered a placement on a four week trial period. Thurlston House DS0000034233.V347481.R01.S.doc Version 5.2 Page 9 All new residents are provided with a Residents Information Pack’ that includes information on complaining about the service and the facilities available. All residents have a signed Terms & Conditions of residence. Feedback from relatives stated that they had received information from the home, which enabled them to decide that they wanted to visit the home to view the facilities and environment. One relative stated in their ‘have your say about CSCI survey: ‘I usually receive information about the home which enables decision making’. Each resident (long stay) has an allocated key worker at point of admission who works with the resident, devising an Individual Care Plan which includes a risk assessment and which is reviewed and updated regularly. Two most recent pre admission assessment records were seen which had been signed by the resident, their relatives and Mr Hutchings and were dated. The information included a pre admission assessment, which was completed before a place was offered at the home and usually co-insides with a care manager assessment. This is to ensure the home can meet the individual’s needs before the placement is offered. The resident’s family were involved and provided further information such as family history and previous jobs. The pre admission assessments included a moving and handling assessment, medical history, allergies, history and risk of falls, equipment needed, personal care needs, personal preferences, medication and any anxieties etc. Mr Hutchings said home provides single accommodation, for one person to receive respite care for a short period of time before they return to their home, or they are admitted into a permanent room if the resident wants to and is assessed as needing residential care. Thurlston House DS0000034233.V347481.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): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive health and personal care based on their individual needs and are treated with dignity and respect whilst their privacy is maintained. EVIDENCE: Mr Hutchings completed the AQAA which states that the home actively promote individual choice and independence in care planning, which includes end of life planning and all relevant risk assessments. Four Care plans seen had been improved greatly since the last inspection. More details about the individual resident’s preferences and how the resident wishes to be supported by staff have been included, staff said that this is an improvement for new staff that have not worked with the resident before. All care plans seen had been reviewed regularly and included the resident’s signature to show they had been consulted in the process and contained the information gathered during the pre admission assessment. Thurlston House DS0000034233.V347481.R01.S.doc Version 5.2 Page 11 Mr Hutchings said that the provider has devised a new format for care plans, which is being piloted in a sister home and will be introduced to Thurlston House in the New Year. Records showed residents had accessed their Doctor. Mr Hutchings said that medication is administered in accordance with the homes policies and procedures by staff who has completed medication administration training. Medication records seen had been completed appropriately. Records for controlled drugs were signed by two staff members and the numbers of tablets remaining were documented. At the time of the inspection there were no residents who were administering their own medication. The inspector observed that staff were attentive, caring, respectful and they have a good understanding of each resident’s individual’s needs. Throughout the visit, staff were seen to knock on doors and wait before entering rooms and they spoke to residents in their preferred manner, as stated in their care plans, and were friendly but respectful. Staff said they are aware of the importance of dignity and respect. Induction records showed that privacy and dignity and the provision of personal care are covered during the induction process, and the response from residents indicated that the carers treat them with dignity and respect and that they are trustworthy. Thurlston House DS0000034233.V347481.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to exercise control over their lives, participate in social activities, receive visits from friends and relatives as they wish and enjoy a choice of meals served in a relaxed atmosphere. EVIDENCE: Mr Hutchings completed the AQAA that states that planned and ad-hoc activities are provided within the home, either by staff or through external providers that are advertised on notice boards. Staff provide support for residents to attend and participate. Residents are encouraged and supported to access the local community and attend church services, day services, luncheon clubs etc. Residents felt they are able to exercise choice by participating in social activities if they wish. Preferences are identified during the assessment process, and this information is included in the individual’s care plan, therefore staff are aware of what residents like doing. Thurlston House DS0000034233.V347481.R01.S.doc Version 5.2 Page 13 Mr Hutchings said that the home meets individual’s cultural or religious interests every effort is made to accommodate these preferences. Mr Hutchings said he is looking into the possibility of employing a part-time Activity Coordinator, to develop a more structured approach to activites. The home has an open visiting policy, this was evidenced by records of visitors to the home and confirmed by residents and relatives who stated they visit the home at different times of the day on a regular basis and are always welcomed. Residents can choose whether or not to receive visitors and whether in public areas or private space. Residents are encouraged to bring in items of furniture and personal effects to help personalise their bedrooms, providing that any such items comply with Health and Safety Legislation. Residents are encouraged to manage their own financial affairs within the realms of their capability and support from other appropriate persons. Mr Hutchings said that they plan to upgrade the equipment in the kitchen over the next few months. Menus are developed within guidelines of the Caroline Walker Trust, under professional guidance and choice is available at all meals. Menus take into account special dietary needs of individuals and nutritional assessments are completed. Whilst residents may choose to eat in their own rooms, individuals are encouraged to eat in the communal dining room, to enable them to socialise with others. Care plans included MUST (Malnutrican Universal Screening Tool) to monitor individual’s risk of malnutrician. We observed refreshments being offered throughout the day for residents, the lunch consisted of two choices of a main course and a dessert, followed by tea or coffee. Homemade cakes and tea were available mid afternoon. Thurlston House DS0000034233.V347481.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. Residents and staff are confident that their complaints will be listened to, taken seriously and acted upon. Staff have a good understanding of Adult Protection issues to fully protect residents from potential abuse. EVIDENCE: Mr Hutchings completed the AQAA that states that residents have written information on how to make a complaint. Hampshire County Councils Compliments and Complaints leaflet is available to all visitors and relatives in main entrance. Relatives cofirmed thet wre aware of the procedure and were confident any concerns raised would be dealt with appropriately. Residents confirmed that the staff are very good and listen to them. Staff stated in their CSCI surveys that they were aware of the home’s complaint procedure which includes the address for the Commission and that all complaints will be dealt within twenty eight days. The complaint log was available which included sufficient detail to monitor complaints successfully. Thurlston House DS0000034233.V347481.R01.S.doc Version 5.2 Page 15 The home have a robust Adult Protection Procedure and all staff are trained on the issues relating to adult protection. Mr Hutchings confirmed that the home have not received or refered any safeguarding adult issues. All staff who responded to the CSCI survey stated that they were aware of the correct procedures to follow if a disclosure of abuse was reported to them, and they had received formal training in abuse awareness, certificates confirmed this. Mr Hutchings confirmed that policies and procedures are reviewed and available for staff to access regarding complaints and protection, staff confirmed this. Thurlston House DS0000034233.V347481.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment continues to be improved to provide residents with a warm and comfortable home. There are good infection control procedures at the home to safeguard the welfare of residents EVIDENCE: Mr Hutchings completed the AQAA that states the home has a maintenance contract for both internal and external areas. A fire manual is kept updated, with specifc information on the occupation of each room, to facilitate evacuation should this be required. Where possible, residents with specific mobility problems are accommodated on the ground floor. Thurlston House DS0000034233.V347481.R01.S.doc Version 5.2 Page 17 A weekly fire alarm test is carried out and all fire fighting equipment, fire alarm system is regularly serviced and maintained. There is a designated room for residents to smoke. Staff and visitors are not permitted to smoke on the premises. Residents bedrooms have been redecorated, making their personal space more pleasing and personal. A new patio area has been created outside the front entrance. Two bathrooms still need updating with specialist baths to better meet the needs of the residents. This was made a requirement at the last inspection. Mr Hutchings confirmed work is underway to ensure the remaining bathrooms are refurbished. Therefore a requirement was not made on this occasion. Mr Hutchings said that equipment in the main kitchen needs replacing, again plans are in place for this refurbishment. The home was warm and clean, residents confirmed this is always the case. The home has domestic and laundry facilities with staff working in these areas trained accordinlgy. Staff said that the home would benefit from more domestic staff, Mr Hutchings acknowledged this and said that a recruitment campagne is underway and are hoping to employ domestic as well as care staff. Infection control procedures were in place. Staff were observed to follow this guidance, equipment such as gloves and aprons were available and the home have a contract with a clinical waste company to ensure bins are emptied regularly. COSHH assessments and information sheets are available for all chemicals used in the home Mr Hutchings explained the majority of maintenance work is completed by a person employed to do so by the home. A maintenance record shows dates when faults were notified and when they were actioned and by whom. Thurlston House DS0000034233.V347481.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to fill the aims of the home and meet the changing needs of residents. Recruitment practices ensure resident’s safety EVIDENCE: Mr Hutchings completed the AQAA that states that rotas are devised according to the dependency levels of residents, using a combimation of Bartel scores and residential forum hours. An experienced duty manager is on duty during the day and a night care coordinator at night time. The home exceed the minimum of 50 of staff trained to National Vocational Qualification (NVQ) level 2 and above. Records are kept of staff training, individual personal plans (IPPs),personal development records (PDRs) and supervision, which occur regularily by a named member of the management team. Thurlston House DS0000034233.V347481.R01.S.doc Version 5.2 Page 19 Staff undertake a core training programme and further training as appropriate to their role profile, to ensure that their knowledge base and skills are kept up to date in accordance with best practice. Four staff responded to the CSCI surveys and were generally happy with everything, comments made about training and support received was good. Staff stated the need for additional staff ‘Occasionally we are short staffed and could provide a better service if we had more staff to provide care and support.’ ‘I believe the manager is currently recruiting.’ ‘We need a bigger domestic team.’ Mr Hutchings confirmed that there is currently a recruitment campaign underway for care and domestic staff. One relative stated: ‘Staff usually have the right skills and experience to provide care properly and usually meet the different needs of people.’ It was evident from practices and interactions observed that staff had developed a good relationship between themselves and residents. Comment from relatives included that staff were very kind and always helpful and that they were a “good team”. The staff stated in their CSCI surveys that the recruitment process within the home is thorough. Staff files were seen and included pre employment checks needed to ensure the persons identification. Criminal Records Bureau (CRB) records showed that the checks had been completed after the person had been confirmed in post. The staff stated that the induction programme run by the home was useful and detailed. Mr Hutchings confirmed that the home’s induction programme meets the recently amended Skill For Care standards for induction standards in line with good practice. Staff confirmed in their surveys to the CSCI that they undertake training regularly in the necessary health and safety subjects such as fire safety, first aid, moving and handling, health and safety, fire training, infection control and food hygiene. Certificates confirmed this. Other training courses attended by staff include nutrition, safe handling of medication, dementia and abuse training. Thurlston House DS0000034233.V347481.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The manager is experienced and competent to run the home. Management and administration of the home is based on openness and respect. An effective quality assurance system is in place. Resident’s finances are safeguarded by the home if residents prefer. Residents’ health, safety and welfare are promoted and protected within the home. EVIDENCE: Mr Hutchings completed the AQAA that states he is Registered with the CSCI as manager and has achieved the fololowing qualifications: an NVQ level 4 in management and a diploma in health and social welfare. Thurlston House DS0000034233.V347481.R01.S.doc Version 5.2 Page 21 Mr Hutchings said he is committed to quality assurance and the continuing development of the service and he had made many improvements since commencing his post, as mentioned throughout this report. Staff stated in their surveys, and observations showed there are clear lines of accountability within the home. Also the management approach of the home creates an open, positive and inclusive atmosphere. Mr Hutchings said that unannounced visit by the service manager; Regulation 26 visits occur on a regular basis, records of these visits were available. The frequency of residents and staff meetings have improved, enabling greater opportunites for involvement in decision making and giving feedback as to how things can be improved. All monies held on behalf of individual residents are held in a secure cabinet and access restricted to the Registered manager and his Duty manager. Records of all transactions are maintained, up to date and accurate and checked monthly by the Registered manager as well as regularly audited by corporate auditors. Residents are encouraged to manage their own financial affairs where possible and with appropriate support to do so. No unsafe practices were observed during the inspection. There is an ongoing system in place that ensures that all appliances are serviced, records and certificates seen indicated that the systems such as the electrics and specialist equipment including hoists receive regular servicing and maintenance. The employer’s insurance liability certificate was displayed and current. Risk assessments where necessary have been completed. Staff have received training in health and safety, first aid, fire safety, control of substances hazardous to health and moving and handling. The fire drill records showed that all staff had attended two fire drills in the last year as well as fire training every six months. Visual checks of all fire safety equipment has been recorded and undertaken at appropriate intervals and weekly fire alarm tests are carried out to ensure the safety of the residents. Thurlston House DS0000034233.V347481.R01.S.doc Version 5.2 Page 22 The home has a policy, procedures and information relating to health and safety Thurlston House DS0000034233.V347481.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 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 Thurlston House DS0000034233.V347481.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Thurlston House DS0000034233.V347481.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Thurlston House DS0000034233.V347481.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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