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Please note that the information on this website is now out of date.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 02/10/08 for St Georges Park Care Centre

Also see our care home review for St Georges Park Care Centre for more information

This inspection was carried out on 2nd October 2008.

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

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

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

People told us that they like living at the home and that the staff are kind and helpful. Staff assess and plan care to take account of peoples` likes/dislikes and preferences and from discussions with people put this into practice. People are cared for by appropriately skilled staff who have a good understanding of the needs of the people accommodated. Observation of a selection of questionnaires recently completed by people living at the home and/or their significant others showed that most people are very satisfied with the home and the care provided. Quality assurance processes and staff access to supervision ensures that quality within the home is monitored and staff have opportunity to reflect on and review care practice. The building provides a spacious and pleasant environment for people to live. People are provided with well-balanced meals, which people say they enjoy.

What has improved since the last inspection?

The garden has been improved and provides people with a well-maintained, safe outside space specifically designed to promote sensory awareness. The home has set up a `support group` for people and their significant others. Observation of how the home records and responds to complaints indicates appropriate involvement of senior management in monitoring and acting on complaints.

What the care home could do better:

We observed that equipment had been stored inappropriately. The home took prompt action when we informed them of our observations and the manager informed us how the home`s lack of storage space should be resolved soon by having access to an outside storage unit. We spoke with the manager and the operations manager about comments which had been made about staffing and our own observations and the operations manager confirmed that as part of his role he will be ensuring the home provides staff according to the dependency of the people who live there. We have made one recommendation as a result of this inspection that, as part of the home`s review of nursing and care staffing levels, the home should also consider increasing the availability of staff who provide activities. This is to ensure that people who are less able to participate in-group activities are provided with opportunities to enhance their well-being. No requirements were made at this inspection.

CARE HOMES FOR OLDER PEOPLE St Georges Park Care Centre School Street St Georges Telford Shropshire TF2 9LL Lead Inspector Rosalind Dennis Unannounced Inspection 09:30 2 October 2008 nd 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 Georges Park Care Centre DS0000022275.V372283.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 Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Georges Park Care Centre Address School Street St Georges Telford Shropshire TF2 9LL 01952 616300 01952 616345 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) Modelfuture Limited, Manager post vacant Care Home 71 Category(ies) of Dementia (32), Old age, not falling within any registration, with number other category (33), Physical disability (6) of places St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N; to service users of the following gender: Either; whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP (maximum number of places 33), Dementia - Code DE (maximum number of places 32); Physical disability - Code PD (maximum number of places 6). The maximum number of service users who can be accommodated is 71. 5th October 2007 2. Date of last inspection Brief Description of the Service: St Georges Park is a Care Home located in St Georges, Telford, and registered to provide personal care, with nursing, for up-to 71 older people, some of whom may suffer from dementia. The Home comprises two Units, Rydal on the lower floor, which can accommodate a maximum of 31 older people who have dementia, and Derwent situated on the first floor, which can accommodate a maximum of 40 older people requiring general nursing care. All bedrooms are single occupancy and with the exception of one room all have en-suite toilet facilities. The Home is owned by Southern Cross Health Care. The range of fees charged by the home varies according to the needs of the individual -the manager confirmed that weekly fees range from £362.55 to £560 depending on people’s needs and whether people need nursing and/or dementia care. Information on fees is included in the home’s statement of purpose. The reader is advised to contact the home to obtain up date information on the fees charged People can obtain information about this service from the home’s Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk. St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was unannounced and was conducted by one inspector over a period of around 8 hours. All ‘key’ standards were assessed during the daythat is those areas of service delivery that are considered essential to the running of a care home. During the inspection we spoke with people living at the home, visitors, staff and the new manager, Liz Muir who was on duty for the duration of the inspection. Time was spent observing and finding out how people spend their days and looking at the interactions between staff and people living at the home. We also looked at care records and other documentation and observed a selection of bedrooms and communal areas. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was sent to the manager for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for providers to share with us areas that they believe they are doing well. It is a legal requirement that the AQAA is completed-St Georges Park returned their completed AQAA to us within the given timescale. Information within this document demonstrates that the manager acknowledges the strengths and weaknesses within the service and is able to plan for improvement. Information provided within the AQAA was used to supplement the inspection process. What the service does well: People told us that they like living at the home and that the staff are kind and helpful. Staff assess and plan care to take account of peoples’ likes/dislikes and preferences and from discussions with people put this into practice. People are cared for by appropriately skilled staff who have a good understanding of the needs of the people accommodated. Observation of a selection of questionnaires recently completed by people living at the home and/or their significant others showed that most people are St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 6 very satisfied with the home and the care provided. Quality assurance processes and staff access to supervision ensures that quality within the home is monitored and staff have opportunity to reflect on and review care practice. The building provides a spacious and pleasant environment for people to live. People are provided with well-balanced meals, which people say they enjoy. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 is not applicable. 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 good assessment and admission procedure, which means that people can be reassured that their needs will be met. Information about the service is made readily available to help people make an informed choice about the home. EVIDENCE: We looked at the care records for two people recently admitted to the service, this shows that assessments are undertaken by the manager before people are admitted and this was also confirmed by one of the relatives we spoke with. The information from the assessments is then used to develop a care plan and identify potential risks to the individual’s health, safety and welfare in the form of risk assessments and the care records we looked at showed these had been completed soon after the person’s admission. St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 10 There is a range of information about the service available, including a Statement of Purpose, a Service User Guide and newly completed ‘welcome guides’, which are informative and easy to read. A ‘photo book’ has also been developed, and the manager described how this is taken to people who are unable to visit St Georges Park before admission so that they can see photographs of the layout of the home to help in their decision-making. Information on how St Georges structures its fees and care packages is included within the ‘Statement of Purpose’ and individual contracts, which provides people with clear information on what is included within the home’s fees as well as information on services which incur additional cost. The service has amended documents to reflect several recent changes within the company at senior level, some minor amendments are needed to the Service User guide and we had reassurances these would be carried out. St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments are generally well written and provide staff with information to meet people’s needs. People who are able to comment on the service are pleased with the care they receive. EVIDENCE: We spent time on both Derwent and Rydal units, speaking with people and visitors, observing staff interactions and looking at care records. People living on Derwent unit who could communicate their views provided positive comments about how they are looked after and described staff as kind, helpful and good. People who prefer to stay in their rooms confirmed that staff regularly ‘check on them’ and help them with drinks and food. People who were unable to speak with us looked well-cared for and positioned well in bed, with appropriate pressure-relieving mattresses in place. St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 12 We observed staff interacting well with people who live on Rydal unit. People looked clean and appropriately dressed. Staff were seen discreetly observing people as they walked around the different areas of the unit. We looked at a selection of care files in both units and found that information within care plans was clear and set out in detail how people want their needs met and the action needed by staff to meet their needs. For example detailed information was included on the level of staff assistance and type of equipment needed to safely move people. Most of the care records we saw for people living on Derwent unit were clear and comprehensive, although the frequency of how often care plans had been evaluated was variable and this was brought to the attention of the manager. Care records we saw on Rydal unit were good and had been updated and evaluated regularly. Information was present on the files to demonstrate that the home seeks advice as necessary from relevant healthcare professionals. Records to show the frequency and amount of diet and fluids were up to date and people were seen throughout the inspection with drinks nearby and staff assisting when necessary. We spoke with people visiting their relatives and all were satisfied with the level of care and other aspects of the home. Examination of a selection of medication administration record sheets found these to be completed accurately, with all medication signed and accounted for. Records showed that medication is generally stored at the correct temperature; it was brought to the attention of the manager that the temperature of the medication storage fridge on Derwent unit had not always been taken daily and had occasionally been too high. St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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. People living at St Georges Park are provided with opportunities to participate in social and recreational interests and are enabled to keep in contact with family and friends. Further consideration is needed to increase the availability of staff who conduct activities to ensure that people who are less able to participate in group activities are provided with opportunities to enhance their well-being Menus provide choice and variety taking into account special dietary needs and personal preferences. EVIDENCE: At the start of the inspection one person was going out to the local shops with the activities person to collect flowers for flower arranging, an activity which takes place on a weekly basis and from comments and observation thoroughly enjoyed by the people who choose and are able to participate. An activities programme is on the notice board in the main reception area and a monthly ‘newsletter’ informs people about forthcoming events, demonstrating that people are provided with opportunities for stimulation through leisure and St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 14 recreational activities. On the day of inspection the home was planning a visit to a local theatre and restaurant. Observations made on Rydal unit show that the activities person and other staff are skilled in promoting positive reactions from people with dementia. The environment on this unit shows that the home is aware of good practice guidance in dementia care and objects seen throughout the unit are placed to promote and encourage responses from people living here. The garden provides people living at the home with a safe outside space specifically designed to promote sensory awareness. Since the last inspection the home has set up a support group for people and their relatives, although observation of minutes suggests this is in its early stage. Observation of recently completed satisfaction surveys show that most people are satisfied with the level and type of activities, although three people had commented they would like to go out more. Records to show attendance at specific activities are based on a ‘tick box’ system and have not been kept up to date. We discussed that these records do not show whether a person has enjoyed the activity, and the activity person and manager described how they are in the process of drawing up specific care plans with people to show individual preferences and capabilities, so that activities can be evaluated by all staff involved in the person’s care. The activities person is full-time, but will work his hours flexibly depending on times people want to do activities. We spoke about how the needs of people living at the home appear to have increased and although the activities person is trying to address this through increased 1:1 activities it is a recommendation of this inspection that the home considers the appointment of another activities person. All people spoken with during the inspection confirmed that meals provided by the home are good, with choices available to meet individual preferences, one person spoke of how they had really enjoyed a salad they’d had instead of a hot meal. Staff were observed providing assistance to people who needed help with eating and drinking and clear instructions were seen in people’s rooms and within their care records to inform staff of how to assist people with swallowing difficulties. The cook was observed assisting with the distribution of the lunchtime meal and demonstrated an eagerness to ensure people receive nutritious, quality food, which caters for different dietary needs. St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that people have access to a clear complaints procedure, which enables concerns or complaints to be dealt with promptly and professionally. Staff are provided with training to equip them with the knowledge and skills to safeguard adults from the risk of abuse or neglect. EVIDENCE: All people spoken with during the inspection confirmed they would feel comfortable in raising any concerns with either the manager or other staff at the home. The complaints procedure is clearly displayed in the Reception area and within written guides about the home. At the last inspection we identified there had been lack of action at a senior level in response to a complaint. At this inspection we looked at the method used by the home to record and respond to complaints and this showed there is a good process in place, which includes records of any corrective action needed, preventative action for the future and involvement of senior management in monitoring complaints. A similar process is also followed if concerns are raised through the local area safeguarding adult’s procedure and we saw information on training included in staff supervision sessions which had been implemented as part of the outcome to concerns. St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 16 There is one outstanding complaint, which also formed part of a safeguarding issue and the outcome of this complaint has not yet been concluded. Information was available to show that staff receive training in adult protection and abuse awareness. St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 17 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 and 26. Quality in this outcome area is, on balance good. This judgement has been made using available evidence including a visit to this service. St Georges Park provides people with an attractive and clean place to live and further planned re-decoration will continue to enhance the appearance of the home EVIDENCE: People living on Derwent unit who we spoke with were satisfied with their bedrooms and en-suites and viewed that their rooms are kept clean. We observed a selection of bedrooms on Rydal unit, the décor of these appeared satisfactory and the floor coverings were clean. There are bedrooms on both units, which would benefit from some updating and the manager confirmed there are plans to renew furniture and textiles as part of an ongoing refurbishment of people’s rooms and we saw an ‘action plan’ detailing such refurbishment and maintenance. A member of the senior management team St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 18 was also conducting a tour of the home at the time of our visit and was identifying where action was needed. During our observations of the environment, we observed that a shower room on Rydal unit was labelled as a temporary storeroom and we found numerous items stored here, however the room had not been fitted with a fire/smoke detection unit and should not have been used for storage. We informed the manager and operations manager of this deficit and immediate action was taken by the home to remove all stored items. The shower has reportedly been out of action for sometime and the home now needs to be prompt in ensuring that this is repaired so that people can be provided with a choice of bathing arrangements. We observed small items of furniture and other items stored at the bottom of staircases and we had reassurances that these would be moved immediately. The manager discussed about how the home’s lack of suitable storage should be resolved soon by having access to an outside storage unit. During the inspection we observed a number of bins without lids, the flooring in the treatment room/office on Rydal unit was stained in areas and a cleaning liquid, had been decanted inappropriately into a container. Discussion with the manager confirmed her awareness of where improvements are needed in respect of infection control and confirmed that specific infection control training is planned for later in October 2008. Examination of a selection of staff questionnaires showed that some staff had raised concerns about cleaning arrangements at weekends, this was discussed with the manager and we were informed that a new cleaner has now been appointed to provide weekend cover. Observation of training records show that staff receive training in infection control and we observed staff washing their hands between procedures and using protective clothing. Staff were also quick to ensure visitors were made aware of infection risks. We observed documentation, which showed that the home is due to be provided with additional cleaning equipment after a successful application for a grant. St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 19 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. People are cared for by staff who are provided with relevant training and support from their managers. The recruitment procedure is robust and protects people from the employment of inappropriate staff. EVIDENCE: Information provided by the new manager shows there has been a significant number of staff who have left over the past twelve months. The home has been recruiting new staff and the staff personnel files we looked at contained all required pre-employment checks. We saw documents, which demonstrate the home provides new staff with a comprehensive induction. We looked at a selection of individual staff training records and the home’s training matrix which shows that a wide range of training is provided-this includes training in safe working practices such as fire safety, as well as more specific training, for example Dementia care and pressure area care. Care staff confirmed that good training opportunities exist and nursing staff spoke of how they are supported to keep up to date with their own professional development. St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 20 Information provided by the manager shows that 61 of care staff have achieved a recognised qualification in care (NVQ level 2). Observation of both units found staff working hard, responding to people’s needs and requests as they arose. At the last inspection we discussed that it would be beneficial to increase the availability of trained nurse input on Rydal unit, this hasn’t happened however the manager informed us that the home is currently advertising for an additional nurse. Staff spoke about how there is usually one less member of care staff on duty in the afternoon on Rydal unit and view that because people’s needs are variable, the unit can be as busy in the afternoon as the morning. Comments on staffing were brought to the attention of the operations manager who confirmed that as part of his role he will be ensuring the home provides staff according to the dependency of the people who live there. The manager also spoke of how the home is looking at providing a member of staff to the reception area so that there is someone available to assist when people first enter the home. St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 21 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, 36 and 38. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The manager, Liz Muir has the skills and knowledge to manage the home and to lead the staff team to ensure people’s needs are met. EVIDENCE: Since the last inspection there has been a change of manager at St Georges Park, as well as changes within the company at a more senior level. The new manager, Liz Muir has worked at the home for sometime and for this inspection demonstrated a good knowledge of the management systems and processes which need to be in place to manage a care home. Liz Muir is currently studying for a management qualification to supplement experience and we have received an application for Liz Muir to be considered for the post of Registered Manager of St Georges Park. St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 22 Observation of ten surveys completed by staff showed that almost all viewed Liz Muir as professional and approachable. During the inspection people confirmed they know who the manager is and provided positive comments on how the home is managed. We looked at an action plan which was drawn up following the results of last years surveys which people living at the home, their significant others, staff and other professionals had completed. The action plan provided a clear overview of where action was needed and by whom. Results from surveys, distributed recently by the home have not yet been collated but those seen show that people are generally very satisfied with the service. For the purpose of this inspection Liz Muir had responded to a request by the Commission to complete an annual quality assessment document (AQAA)- this is an opportunity for providers to share with us areas that they believe they are doing well, and where they could improve. The information contained within the AQAA shows that Liz Muir acknowledges the strengths and weaknesses within the service and is able to plan for improvement. We looked at documents, which demonstrate that meetings are held on a regular basis to keep staff informed of changes within the service, implementing good practice and where changes to practice are needed. Staff confirmed they have access to formal supervision sessions, which provide opportunity to reflect on their practice and to discuss training and development needs. Information was provided within the AQAA to confirm that servicing and maintenance of equipment is undertaken and policies and procedures are regularly reviewed. The selection of records we looked at, including fire safety and water temperature checks, were all up to date. Apart from the deficits described in the Environment section of this report, this inspection shows that St Georges Park promotes and protects the health, safety and welfare of people living at the home, staff and visitors. St Georges Park Care Centre DS0000022275.V372283.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 3 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 St Georges Park Care Centre DS0000022275.V372283.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. 1 Refer to Standard OP27 Good Practice Recommendations As part of the home’s review of nursing and care staffing levels, the home should also consider increasing the availability of staff who provide activities. This is to ensure that people who are less able to participate in group activities are provided with opportunities to enhance their well-being St Georges Park Care Centre DS0000022275.V372283.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Georges Park Care Centre DS0000022275.V372283.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. 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!