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Inspection on 19/07/07 for St George`s (Wigan) Limited

Also see our care home review for St George`s (Wigan) Limited for more information

This inspection was carried out on 19th July 2007.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides different lounge areas for residents to have choice as to where they sit and with whom they choose to spend time with. Visitors are made welcome at any time and are made to feel welcome by staff when visiting relatives and friends. The home has set up "The friends of St Georges", which meet regularly to discuss fund raising and what they think the home, residents and staff would benefit from. The group offers moral support and friendship for people who have relatives living at the home. Good relationships have been formed between residents, relatives and staff. The acting manager holds daily nurses meetings where staff and the manager discuss the resident`s health, any changes, and any staffing issues. The acting manager keeps minutes of the meetings.

What has improved since the last inspection?

The acting manager has produced a separate statement of purpose for the dementia unit downstairs. The unit is known as the George Formby Unit (due to the stars links with Wigan). The booklet provides residents and their supporters with information about the unit and about the staff who work mainly on the unit. At the time of the inspection the George Formby Unit was closed due to a full refurbishment of flooring, bedrooms with new fittings and furnishings, bathrooms and toilets and the corridors. The work was near completion and residents living on the unit were due to move back in to their rooms. The acting manager has purchased 13 new nursing beds, 1 electric high/low bed, 30 medium to high pressure relieving mattress and 4 active overlay mattress to ensure that residents needing bed rest can be nursed in comfort. The acting manager is working closely with outside agencies for example speech and language therapist, the falls clinic, the tissue viability nurse, diabetic clinics and physiotherapists. More activities are now offered to residents, families are welcome and encouraged to also participate. The garden area has been made more accessible for resident, with a patio area and suitable garden furniture. New menus have been introduced and now include a starter with the lunchtime meal for example melon, grapefruit or mandarin oranges. The home now employs an activities coordinator four days a week that has introduced a wide range of activities including tea dances and entertainers to come into the home and present different themed days for example country and western dances.

What the care home could do better:

The home`s acting manager is aware of the areas of the home that still need to be improved and is continuing to work to ensure high standards of care are provided and maintained.

CARE HOMES FOR OLDER PEOPLE St George`s (Wigan) Limited Windsor Street Wigan Lancashire WN1 3DG Lead Inspector Judith Stanley Unannounced Inspection 19th July 2007 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 George`s (Wigan) Limited DS0000055720.V337739.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 George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St George`s (Wigan) Limited Address Windsor Street Wigan Lancashire WN1 3DG 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) 01942 821399 pauline@sgnh.f2s.com St George`s (Wigan) Limited Care Home 62 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (12), Old age, not falling within any other of places category (38), Physical disability (6), Terminally ill (6) St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered for a maximum of 62 service users to include:up to 38 service users in the category of OP (Older People) up to 12 service users in the category of DE(E) (Adults with Dementia over 65 years) up to 2 service users in the category of DE (Adults with Dementia under 65 years) up to 6 service users in the category of PD (Physical Disability under 65 years) up to 6 service users in the category of TI (Adults with Terminal Illness) The service should employ a suitable qualified and experienced manager who is registered with the Commission for Social Care Inspection. Two named service users in the category of DE (Adults with Dementia under 65 years) may be accommodated within the overall number of registered places Sufficient staff must be on duty at all times who are trained and competent to meet the needs of service users, taking account of changing dependency levels and special needs. 6th July 2006 2. 3. 4. Date of last inspection Brief Description of the Service: St. Georges has been operating as a care home since 1990 and has facilities to provide nursing and personal care for up to 62 residents in a range of accommodation, including single and shared rooms. A small dementia care unit offers care and accommodation for residents with dementia related illnesses. The home is situated within walking distance of Wigan town centre and is close to local shops and other facilities, including a large superstore. There is a large garden at the back of the home with patio area and seating for residents to sit outside. The home has a private car park and parking is available on the road outside the home. Public transport is easily accessible. The Home is a ten to fifteen minute walk from the bus terminal and the railway station. Access to the motorway network is also nearby. St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 5 The current scale of fees at St Georges ranges from £367.01 to £466.01. Additional charges are made for hairdressing and chiropody. St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to St Georges took place on the 19 July 2007 and included a site visit. The inspection was carried out from 09:00 am until 16:40 pm. The inspector looked at records the home hold on residents (care plans) and other records the home needs to keep to ensure the home is being run properly. The inspector looked around the building with the acting manager and then spent time alone looking around the home and speaking with staff, resident and relatives. Comment cards, asking residents, relatives and other visitors to the home what they thought about the home and the care provided were sent out prior to the inspection. Three residents and seven relatives returned comment cards. One resident said that she liked the meals at the home and that the home was always clean. Two residents said they had not received contracts or statement of terms and conditions. Resident’s comments indicated satisfaction of the care provided at the home. One relative stated, “ On visiting the home you are made welcome. The home and my dad’s room are always clean and tidy. The staff including, the manager are always friendly and chatty”. Another relative stated, “I have never needed to raise any concerns about the care my mother receives the staff have always been excellent”. In the main the relatives comments indicated overall satisfaction with the home and staff. The acting manager said there had been two complaints made since the last inspection, these had been suitably dealt with by the acting manager within an appropriate timescale and all information was documented. There have been no complaints made to the CSCI. What the service does well: The home provides different lounge areas for residents to have choice as to where they sit and with whom they choose to spend time with. Visitors are made welcome at any time and are made to feel welcome by staff when visiting relatives and friends. The home has set up “The friends of St Georges”, which meet regularly to discuss fund raising and what they think the home, residents and staff would benefit from. The group offers moral support and friendship for people who have relatives living at the home. St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 7 Good relationships have been formed between residents, relatives and staff. The acting manager holds daily nurses meetings where staff and the manager discuss the resident’s health, any changes, and any staffing issues. The acting manager keeps minutes of the meetings. What has improved since the last inspection? What they could do better: St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 8 The home’s acting manager is aware of the areas of the home that still need to be improved and is continuing to work to ensure high standards of care are provided and maintained. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 was assessed. Standard 6 does not apply at St Georges. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are not made until a full needs assessment has been undertaken and a decision has been reached that the home can meet an individuals needs. EVIDENCE: A selection of care plans were chosen for inspection from each of the services offered within the home. A total of eight care plans were inspected and there was evidence to show that pre admission assessments had been carried out prior to a resident being admitted into the home. The assessment is carried St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 11 out at the most convenient place for the prospective resident, either at their own home or in hospital by the acting manager or a by a qualified nurse. During the assessment and to ensure the needs of the residents can be fully met a mini mental state examination (MMSE) is completed to help determine a person’s mental state and cognition and prepare the mild, moderate or severe dementia care plan. The assessment also covers the individuals personal care and general wellbeing, diet, allergies, medication, sight, hearing and communication, history of falls, mobility, continence, likes and dislikes and social interests and pastimes. The assessment provides staff with the information they need to offer the care the individual needs and expects and is the base line for the drawing up of the care plan. St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a consistent care planning system in place to provide staff with the information they need to satisfactorily meet the resident’s needs. Personal support is offered in such away as to promote and protect resident’s privacy and dignity. EVIDENCE: Eight care plans were chosen for inspection. There has been continued improvement to the care plans and in the amount of information they now contain. The care plan is a working tool and provides staff with the information they need to ensure the residents receive the care and support they need. St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 13 Care plans contained information on resident’s personal details, personal preferences, medication, past medical history, nutritional needs, skin tact, mobility, falls, likes and dislikes and social interests and pastimes. Other information included relatives’ communication sheets as to when and why relatives were contacted, out patients appointments, hospital transfer sheets and daily progress notes. Risk assessments were in files for moving and handling, falls, pressure/skin care, use of bed rails and going out of the home unaccompanied. There was evidence that showed that outside agencies were contacted for advice and support as necessary, for example if any residents are assessed as having grade 2 pressure sore or above they are automatically referred to the tissue viability nurse. There is also involvement with the speech and language team, the falls clinic, diabetic liaison and with physiotherapists. The acting manager has introduced a “This is me booklet”, which provides staff with a more person centred approach about the individual. For example, “ I was born on/at, I lived at, my family included or includes, the things I enjoy are, I went on holiday to”. This gives an insight into the resident life and helps staff generate topics of conversation. The inspector observed part of the morning’s mediation round. The nurse in charge of the floor was seen to give out the medication is a swift and efficient manner. The individuals MAR sheet (drug sheet) was completed immediately after the medication was given. Currently there is no one at the home who administers their own medication however a policy is in place should this arise and lockable storage in resident’s rooms would be provided. All drugs were seen to be suitably and securely stored. The inspector observed throughout the day that residents were spoken to and treated with respect. It was evident that good relationships had formed between the staff, residents and with their families. Staff had received instruction and a handout about promoting privacy and dignity within the home. One example observed being staff adjusting a residents clothing when using the hoist. The acting manager has particularly emphasised about promoting privacy and dignity when residents share a room making sure this is maintained. St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a choice of well-planned and well-cooked meals in a choice of settings. EVIDENCE: The home has an activities coordinator who, with the help of residents and relatives and the “Friends of St Georges” plans a range of activities and fund raising. Activities for 2007 include foot massage, manicures, draughts, dominies, cards, skittles, reminiscence, trips to local shops and supermarkets. The home has planned through to Christmas 2007 for outside entertainers to visit the home, these days usually have a theme e.g. country and western or tea dances. Relatives are welcomed and encouraged to participate. A separate activities programme is available for residents living on the George Formby Unit. For example on Tuesday and Thursday, as part of the core activities staff work with individual residents carrying out some domestic tasks St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 15 such as dusting and tidying their own rooms. On other days residents bake or polish their shoes, if they wish to. The home has regular visits from the priest attached to the local Roman Catholic Church and the acting manager is currently looking to obtain the services of a multi denominational minister for other residents. The home welcomes visitors at any time. The only restriction imposed is that where possible visitors leave the building at about 20.00 pm to allow the night staff to secure the building for the night. On the day of the inspection relatives were seen in the home at meals times with one relative supporting her husband to have his lunch. There are numerous areas on each floor where residents can spend time with their visitors or they are welcome to spend time with them in the privacy of their own rooms. Where possible residents are encouraged to exercise control over their lives and are helped and supported by staff in doing so. Residents have the choice of when they get up and when they go to bed and what clothes they wish to put on. Obviously for some residents choices can be difficult to make, therefore staff need to have input in helping them with some decisions and choices. The summer menus were available for inspection. The menus offer a good choice at breakfast time including porridge, cereals, grapefruit, eggs, cheese on toast, or anything else residents requests. Lunch is the main meal of the day, there is always a fruit starter followed by two choices of main meal and other snacks are available such as jacket potatoes with various fillings, soups, omelettes and sandwiches, followed by a dessert. A lighter afternoon tea is served; again choices are available. Any special diet can be catered for e.g. pureed diet or soft diets. Fresh fruit is available in the lounge and mid morning and afternoon drinks and biscuits are served. A choice of supper is available including sandwiches, cakes and biscuits, tea, coffee and milky drinks. The main dining room is on the ground floor, however there is a small dining area on the top floor. Some residents were seen dining in the lounge areas and some in their rooms. St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 16 The inspector noted that suitable crockery and cutlery was available and that staff were available to assist those residents that needed help. St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 17 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 and 18 were assessed Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a clear complaints system and satisfactory arrangements are in place to protect residents from abuse in any of its forms. EVIDENCE: The home has a complaints procedure, which is displayed near the main office. In the returned comment cards relatives made it clear that they would speak with the acting manager if they were not happy. There have been two complaints made to the acting manager since the last inspection. Both have been suitably dealt with by the acting manager within the appropriate timescale. The home has up to date policies and procedures in place on the protection of vulnerable adults. All the trained staff had attended training on the protection of vulnerable adults and other staff had received handouts and had signed to say they have read it. Although the home covers the different types of abuse as part of their induction and has purchased two videos on abuse, it would be beneficial if all staff, attended the same training as the qualified staff. St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 18 The acting manager has made one referral to the Protection of Vulnerable Adults list (POVA) since the last inspection and the acting manager notified other agencies as required. St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 19 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, 25 and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of décor within the home is good, with evidence of improvement through maintenance and future planning. The home presents in a homely, clean comfortable environment for residents to live in. EVIDENCE: Prior to registration St Georges was a school and is a Grade 2 listed building. The home from outside still looks like a school. It is not possible to change the outside and inside the home has corridors and stairs as would be found in a typical old school. The acting manager and her staff have tried hard to make the home comfortable and welcoming with the facilities available. There has been a lot of financial input to ensure standards are maintained. St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 20 On entering the home the reception area is comfortable and clean and welcoming to residents and relatives and is a pleasant area to sit in. The George Formby Unit on the ground floor was closed at the time of the inspection for a full refurbishment. All bedrooms had been decorated, new flooring laid throughout. All the bathrooms and toilets had been decorated and been fitted with suitable aids for example raised toilet seats and grab rails and new taps that turn themselves off to prevent flooding. All new bedding and furnishing had been purchased. The lounges had been decorated with new carpets fitted and new chairs bought. The lighting has been changed on the corridors; this was seen too be much brighter and better for the residents. The garden area now has a patio with wheelchair access. Appropriate seating is available and a large awning has been erected to protect residents from the sun. Infection control procedures were observed to be good. The acting manager has purchased wheelie bins for staff and domestics to take to bedrooms to stop the use of wet or soiled laundry being carried around the home. Staff were observed wearing different protective clothing for different tasks. The laundry is sited on the ground floor away from food preparation and food storage areas and does not intrude on the residents. The home was clean and tidy and no odours were detected. St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 21 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that they are being cared for by staff that are trained and competent to do their job efficiently and effectively. EVIDENCE: On the day of the inspection there were sufficient numbers of staff on duty. As this is a large home staff may not always be visible at all times. The staff rosters were available for inspection. Staff morale was good and several of the staff had worked at the home for a number of years and were complementary about the acting manager, her style of leadership and the changes that she had made within the home. The acting manager confirmed that absentee and sickness leave had dramatically reduced and that staff are rewarded for their loyalty and commitment. NVQ training is ongoing with 33 of staff having achieved NVQ level 2 and a further 10 staff hoping to complete this summer. St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 22 Most of the catering staff have completed an NVQ in cookery and the domestic staff in housekeeping. All new staff employed has to be willing to undertake NVQ training as part of their employment. Staff had completed mandatory training and updates as and when required. Three staff files chosen for inspection showed satisfactory recruitment procedures were evident. Staff files included a written application form, 2 written references; Criminal Records Bureau checks and some had other forms of identification. St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 23 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 and 38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their supporters can be assured that the home is being managed by a competent, well-trained and experienced person with oversight and skill to provide good quality safe and inclusive care to residents. EVIDENCE: The acting manager has been in post for over twelve months and has made application to the CSCI for the post of registered manager. This process has been held up through an administrative error. St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 24 The acting manager has many years experience in managing staff and working with the elderly and is suitably qualified, competent and capable of running the home. The acting manager has made vast improvements within the home and with the paperwork and documentation. Staff spoken with said they felt happier in their work now that there was properly leadership and structure within the home. Staff and relatives said they felt comfortable in approaching the acting manager at any time. Quality assurance systems within the home were good. The acting manager carries out monthly audit checks on medication, accidents, meals, the environment, care plans. The owner of the home carries out monthly visits as required and copies of his reports were available for inspection. The home holds regular staff, residents and relatives meetings. The “Friends of St Georges” meet regularly to discuss and voice their opinions on events and occurrences within the home. The acting manager is well supported by an organised and experienced administrator. The administrator oversees the resident’s finances. In the main families deal with resident’s finances, however the home does hold small amounts of money for some residents. The resident’s money is held in one main account (no interest accrued) and individual balance sheets are kept on computer. Receipts of any transactions are kept. This system appears to work well at St Georges. Health and safety policies and procedures were in place to ensure the welfare and safety of residents and staff. All the homes policies had been recently updated and staff has access to these. Prior to the inspection the acting manager provided the CSCI with information stating that regular service and maintenance checks had been completed. A random check of certificates showed the following: Lift serviced – April 07 Hoist were due July 07 Electrics – not due again until July 11 Gas`- booked to visit – July 07 Portable equipment – March 07 Water testing – June 07 The accidents file was available for inspection and all accidents, incidents and injuries were suitably recorded and the CSCI informed as necessary. St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 25 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 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 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 x x 3 St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 26 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. 1. Refer to Standard OP18 Good Practice Recommendations The manager should make sure that all staff complete planned training in relation to the protection of vulnerable adults. It is recommended that fifty per cent of care staff complete training to NVQ Level 2 or equivalent. The manager should make sure that her application to be registered with the Commission is submitted as soon as possible. 2. 3. OP28 OP31 St George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 George`s (Wigan) Limited DS0000055720.V337739.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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