Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 06/07/06 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 6th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

Care is provided in clean and homely surroundings in which the residents feel safe and well cared for. Good relationships have been developed between residents and staff so that residents feel satisfied and cared for. Arrangements for dealing with complaints are good and residents know how and who to contact if they have any concerns.

What has improved since the last inspection?

Staff now have access to care plans and use them regularly to make sure that they are delivering the care needed and are aware of any changing needs. Concerns about staffing arrangements in the home have largely been addressed and outcomes for residents in relation to nursing and personal care have improved. The recent appointment of a nurse trained to care specifically for people with mental health problems has improved the care provided to residents in the dementia care unit. An ongoing programme of refurbishment has improved the standard of accommodation for residents.

What the care home could do better:

The home needs to make sure that enough adjustable beds are provided to help staff manage the health care needs of residents properly. The arrangements for making sure that staff promote residents` rights to privacy, dignity and respect need to be more consistent so that care practices support the home`s stated purpose. The recruitment processes are poor and not thorough enough to make sure that the residents are properly protected. Quality assurance systems need developing so that the home cam make sure that residents views are obtained about the quality of service provided.

CARE HOMES FOR OLDER PEOPLE St George`s (Wigan) Limited Windsor Street Wigan Lancashire WN1 3DG Lead Inspector Anne Taylor Unannounced Inspection 09:30 6 & 11th July2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 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.V288645.R01.S.doc Version 5.1 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 wigan@stgeorgescarehomes.co.uk St George`s (Wigan) Limited Ms Julie Melling 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.V288645.R01.S.doc Version 5.1 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. 28th November 2005 2. 3. 4. Date of last inspection Brief Description of the Service: St. Georges Nursing Home is situated within walking distance of Wigan town centre and is close to local shops and other facilities, including a large superstore. 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. 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 building is Grade II listed and was previously a school before being converted to its present use. As of April 2006 the fees at St Georges range from £360.59 up to £453.00. Additional charges are made for hairdressing and chiropody. Information about the facilities and services provided can be found in the home’s statement of purpose and service user guide. St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 5 St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This report has been written using information held on CSCI records and information provided by people who use the service, their relatives, the manager and staff at the home. A site visit to St Georges took place on the 6th July 2006 and again on the 11th July 2006, in total the inspector spent 13 hours at the home. The home had not been told beforehand of when the inspector would visit. The inspector looked around the building and looked at paperwork that has to be kept to show that the home is being run properly. To find out more about the home the inspector spoke with residents, visitors, trained nurses, care staff the cook, the administrator and the manager. Comment cards asking residents, relatives and professional visitors what they thought about the care at St Georges had been given out a few weeks before the inspection. A small residents and relatives filled the cards in and returned them to the CSCI. For the purposes of this inspection, because there are only a small number of people living at the home who are under the age of 65, the National Minimum Standards for Older People formed the basis for measuring the standard of care provided. What the service does well: What has improved since the last inspection? Staff now have access to care plans and use them regularly to make sure that they are delivering the care needed and are aware of any changing needs. Concerns about staffing arrangements in the home have largely been addressed and outcomes for residents in relation to nursing and personal care have improved. The recent appointment of a nurse trained to care specifically St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 7 for people with mental health problems has improved the care provided to residents in the dementia care unit. An ongoing programme of refurbishment has improved the standard of accommodation for residents. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information needed to choose a home that can meet their needs and have their needs assessed before they come to live at the home. EVIDENCE: The home has developed a service user guide that provides up to date information about the facilities and services available. The guide is available in standard, large print and picture formats and given to any prospective resident or their representative. Evidence suggests that prospective residents have a needs assessment carried out before they are admitted to the home to make sure that individual needs can be met. The home is able to show that an appropriately trained person has completed the assessment regardless of whether the funding is private or paid by the local authority. Evidence also shows the assessment is completed St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 10 professionally and has involved the family or a representative. The home is able to show that they receive copies of care management summaries and care plans from those assessments carried out through care management arrangements. St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The approach to the management of health and social needs is improving and outcomes for residents therefore better. EVIDENCE: There have been noticeable improvements made in relation to care planning and the management of health care needs since the last inspection. The home’s policy is to develop a plan of care for each resident on or shortly after admission and all residents have a plan of care. The care plans seen include information necessary to plan individual care, risk assessments and risk management plans that help promote the health, welfare and safety of residents. The home should ensure that all nursing assessments are dated and signed by the person completing the assessment. Social needs are not currently included in the plan of care so staff might not be aware of individual needs and wants in relation to this aspect of their care. St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 12 Staff have access to care plans and use them regularly to make sure that they are delivering the care needed and are aware of any changing needs. Evidence of updating information and changing actions appears on care plans and some relatives confirm their involvement in developing and reviewing the plan. Care practices are supported by policies procedures and practice guidance so that staff are clear about what is expected of them and are familiar with best practice. Staff are able to discuss the needs of the people they care for and how they manage and meet those needs Residents seem to have access to health care services within the home and the local community. Health is monitored and action taken to seek advice from other health care professionals when needed. There is evidence in the care plan of health care treatment, intervention and general health information including weight monitoring and nutritional information. Since the last inspection the home has increased the number of pressure relieving mattresses and cushions and evidence suggests that any pressure sores are being appropriately managed. The home provides care for a number of residents with chronic chest conditions that require them to receive continuous oxygen therapy and be nursed upright. At present the home has only one adjustable bed and everyone else is nursed on divans beds. Staff say that they “prop” residents up with bedding if they need to sit up in bed. This is very poor practice and the home must make sure that they have the right equipment available in the home to meet assessed need. Residents at St Georges do not administer their own medication but would be supported to do so if they wished. Qualified nurses administer all prescribed medicines. The pre-printed medication administration records (MAR) are generally up-to-date, but some handwritten entries are not signed, independently checked and countersigned. The medication storage is orderly and secure and the refrigerator temperature recorded. New arrangements have been made for the disposal of medicines; the procedures have been updated to reflect this change, and staff are familiar with the new arrangements. The home has policies and procedures that cover the rights of residents including the right to respect, privacy and dignity. The home’s policy is to make sure these topics are covered during induction. Staff are able to discuss how they respect the privacy and dignity of the people they care for. However, some residents say that staff do not always knock before entering their bedroom or knock but do not wait for an answer before they come in and this can sometimes be embarrassing. Some care practices observed during the inspection do not support or promote residents’ rights to dignity, privacy and St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 13 respect and staff are not consistently putting the home’s polices and procedures into practice. St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements for organising daily life are generally satisfactory although more attention should be paid to making sure all residents are supported to make choices if they are able. The provision of social activities does not consistently meet the expectations of residents. EVIDENCE: Polices and procedures promote residents independence and the right to live in a flexible environment where their choice of routines and activities forms part of the homes philosophy of care. However, the routines of the home are not always planned around residents needs or wishes and the service needs to be more flexible in consulting residents about their preferences in relation to the routines of daily living. Some residents felt that they did not have a choice about what time they get up or go to bed and that they have to fit in with the needs of staff. The home has developed a system for displaying information and bringing attention to events and activities which residents enjoy. St Georges has recently developed a “pen pal” relationship with a care home in America. They St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 15 swap emails, photographs and share information, which residents in both homes seem to enjoy. Resident are able to use the homes Internet facility during office hours. There is a mixed response to how good the home is at providing activities. In general residents seem satisfied but some residents feel that there is not enough for them to do and they get quite bored. An activities organiser is in the home for four days each week and staff say that they try to provide activities and stimulation for residents when she is not there. The dementia care unit has a range of visual display items and the activities person consults the unit manager to make sure the range of activities available is suitable to their specific needs. Family and friends are made welcome and know they can visit the home at anytime. Information about visiting is in the homes statement of purpose and service user guide. Staff try and make time to talk to visitors and share information with the agreement of the resident. Seating areas are provided in the home within communal areas where residents can see their visitors or they can use their own bedroom. However the large number of shared rooms means that this is not always an option for some residents as their bedroom is not completely private. Information provided by the home indicates that the residents currently living there do not manage their own finances. Policies and procedures promote the right of residents to manage their own financial affairs and the manager and administration staff confirm that they would support any resident to do this and would also access advocacy services if needed. There has been a significant improvement in relation to food served at the home since the last inspection. Food in the home is of a good quality, well presented and meets the dietary needs of residents. The cook consults with residents and the home manager. She tries to meet the preferences and suggested dishes when preparing menus. Staff help those residents who need help when eating and are sensitive in their approach. Residents enjoy the flexibility of meal arrangements and enjoy being able to eat in their own room if they wish. Regular dinks and snacks are available throughout the day and night. Staff will always make a cup of tea at anytime when asked. Tables are set attractively with necessary cutlery and aid to help individuals during their meal. St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to a clear complaints procedure, and satisfactory arrangements are in place to protect them from abuse. EVIDENCE: The home has an up to date complaints procedure that meets the National Minimum Standards and Regulations. The complaints procedure is displayed within the home and residents know how to make a complaint. A copy of the complaints procedure is included in the service user guide and the home’s policy is to provide each prospective resident with a service user guide before they come to live at the home. Polices and procedures regarding protection are satisfactory are up to date and are in line with regulations and other external guidance. Within the policy it is clear when incidents need external input. Links with external agencies are satisfactory and includes CSCI, police and adult protection teams. Staff can demonstrate an awareness of the policy and know what immediate action to take and when and who to refer any incident to. Training has been provided for all trained nurses and training dates arranged for all other care staff in August 2006 so they are up to date with legislation and current best St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 17 practice. Residents and others associated with the home say that they are satisfied with the service provision and feel safe and supported. St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home is fit for its stated purpose but improvements are needed to make sure the environment is maintained to a good standard that will benefit residents. EVIDENCE: The service provides a clean comfortable environment that is free from offensive odours and has a rolling programme to improve the decoration, fixtures and fittings. A lot of work has been carried out since the last inspection to try and improve environmental standards at the home. Some residents have benefited from this as their personal accommodation has been redecorated and refurbished. Some communal areas have also been upgraded and new furniture and floor coverings bought, however, parts of the home including St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 19 some personal accommodation still need improving to make sure that all residents are able to live in pleasant surroundings that are adequately lit. Residents say that they are comfortable, the home is clean and warm and there is enough hot water. Some of the lighting in bedrooms is not sufficiently bright enough to allow reading, writing or other activities. The dementia care unit provides a safe environment for the people accommodated there and the residents are able to wander freely around the unit if they wish. There are a number of single rooms, a few double rooms and only one bedroom with an en-suite facility. Staff say that residents or their relative make an informed decision about whether to share a bedroom or not and residents that initially choose to share are offered a single room if one becomes available. There are a number of bathrooms and toilets around the home that are clearly marked and some assisted baths are provided. New floor covering has been laid in bathrooms and toilets and the decor improved so that the facilities are more pleasant for residents to use. The lawned garden outside is quite large and seating is available for residents. However, Access to the garden is not easy for the less mobile or people that use wheelchairs. The home has infection control policies in place that provide guidance and information for staff. Some staff have received infection control training and are able to discuss how they manage infection control at the home. Laundry arrangements are satisfactory and staff say that there is always enough clean linen available. Residents say that their clothes are washed, returned and put away quickly. St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. Staff in the home are employed in sufficient numbers to meet the aims of the home and training is provided for staff that will help them to do their jobs effectively. The recruitment processes are poor and not thorough enough to make sure that the residents are properly protected. EVIDENCE: Residents have confidence in the staff that care for them and are satisfied with the overall standard of care received. Rotas show that the home is staffed appropriately with a suitable skill mix of staff. The recent appointment of a nurse trained to care specifically for people with mental health problems has improved the care provided to residents in the dementia care unit. There is very little use of agency staff and residents receive care from people they know and have established relationships with. Staff are encouraged to undertake external qualifications and vocational training is available to all care staff. Currently twenty-six per cent of care staff has a nationally recognised care qualification and the home is working towards achieving the fifty per cent needed to meet the national minimum standard. St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 21 The new manager has developed an annual training and development programme after completing training needs analysis for staff as part of the home’s appraisal process. The organisation provides job descriptions and staff are clear about their roles and what is expected of them. The service has a good recruitment procedure that clearly defines the process to be followed but the procedure is not being carried out in day-to-day practice. Staff are being confirmed in post before all background checks have been completed despite this being a requirement at the last inspection. Although there has been progress made in relation to staff development there are ongoing concerns about the protection of vulnerable residents and an important key standard is not being met. This presents a significant risk and has affected the quality outcome in this area. St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Management systems and processes have improved so that the overall standard of service is better. EVIDENCE: The manager is new in post at St Georges. She is in the process of applying to be registered with the Commission as home manager. Staff feel that the manager’s approach is open and inclusive and that motivation and morale has improved since she came. A statement of purpose that sets out the aims and objectives of the home is in place and available to residents and any other interested parties. The organisation needs to develop systems that monitor practice and compliance St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 23 with the home’s plans policies and procedures and be able to show that they seek regular feedback on the quality of service delivered to make sure the home is being run in the best interests of the people who live there. In addition the report of monthly visits to the home made by the registered provider need to include the views of people that live and work there in order to form an opinion of the standard of care provided. Residents have the opportunity to manage their own finances if they wish and facilities are provided to help keep it safe. Where the home manages money on residents’ behalf a system is in place to record transactions and accounts for spending. Checks show that records are up to date and entries are clear. Residents are satisfied with the systems for handling or helping manage their money. A health and safety policy is in place that generally meets health and safety requirements and legislation. The management team are aware of any areas where they need to make improvements and have a plan for undertaking the work. Health and safety records are generally satisfactory and are routinely completed. However, the electrical installation certificate is out of date and the fire risk assessment should be reviewed and advice sought from the local fire authority regarding its content to make sure the home is complying with current legislation. Polices and procedures are in place and being reviewed and updated with the manager to make sure they reflect current legislation and best practice guidelines. Staff have access to the homes polices and procedures and the manager holds regular staff meetings that provide a forum for staff to discuss any changes. St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 2 St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP7 OP7 Regulation 12 16 Requirement Care plans must contain sufficient information about social care needs. Equipment must be provided that is appropriate to a person’s nursing needs. (Timescale of 31/01/06 not met). The Home must be conducted so that the privacy and dignity of residents is promoted and maintained. (Timescale of 28/11/06 not met). Residents must be consulted about the programme of activities they would like and a programme of activities developed that meets their needs and wishes. (Timescale of 31/01/06 not met). Residents must, so far as they are able, be supported to make decisions about the care they receive and their lifestyle. The garden must be made accessible for residents living at the home. (Timescale of 01/05/06 not met). Timescale for action 31/08/06 30/09/06 3. OP10 12 31/08/06 4. OP12 16 31/08/06 5. OP12 12 31/08/06 6. OP19 23 30/09/06 St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 26 7. OP25 23 8. OP29 19 9. OP33 12 10. OP33 26 11. 12. OP38 OP38 23 23 Lighting must be provided throughout the home that is suitable and meets recognised standards. (Timescale of 31/12/05 not met). Staff must not be employed without two satisfactory references, POVA and CRB checks. (Timescale of 01/12/05 not met). A system must be established to seek feedback from residents regarding the quality of service delivered so that the home can be conducted in a way that takes into account the needs, wishes and feelings of residents. Visits to the home made by the registered provider must include interviews, with their consent, of residents, their representatives and persons working at the care home. An up to date electrical installation certificate must be submitted to the Commission. The fire risk assessment must be updated and advice sought from the local fire authority regarding its content. 30/09/06 31/08/06 30/09/06 30/09/06 30/08/06 30/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP9 OP18 Good Practice Recommendations All nursing assessments should be dated and signed by the person completing the assessment. Handwritten entries on medication administration records should be signed, independently checked and countersigned. The manager should make sure that all staff complete DS0000055720.V288645.R01.S.doc Version 5.1 Page 27 St George`s (Wigan) Limited 4. 5. OP28 OP31 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. St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St George`s (Wigan) Limited DS0000055720.V288645.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!