CARE HOMES FOR OLDER PEOPLE
St Georges Park Care Centre School Street St Georges Telford Shropshire TF2 9LL Lead Inspector
Keith Salmon Key Unannounced Inspection 30th November 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Georges Park Care Centre DS0000022275.V320252.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.V320252.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, 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.V320252.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 71 Nursing beds which may include a maximum of 10 residential beds, including 32 older people with dementia on the ground floor and up to 6 residents with a physical disability on the first floor. 22nd May 2006 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 and the Manager is Debbie Baron. Weekly fees range from £304 to £500. St Georges Park Care Centre DS0000022275.V320252.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This ‘Key’ Unannounced Inspection commenced at 09.30am, concluded at 2.00pm (a total of 4.5 hours) and was conducted by Mr Keith Salmon. Present throughout the Inspection was the Registered Manager, Debbie Baron. The main objective of this Inspection was to review all of the ‘Key’ Standards, as set out on the National Minimum Standards for Care Homes for Older People, plus Standards 1 and 2 as part of a ‘thematic’ survey being undertaken by CSCI at the time of this Inspection. Also, the Inspector reviewed progress made by the Home in meeting ‘Requirements’, arising from the previous Inspection held on 6 December 2005. This Report is a product of observations made during a tour of the Home, a review of care related documentation, staff duty rotas and staff files, plus a range of documents/records reflecting the general operation of the Home. The Inspector also held discussions with the Manager, 6 Residents, 2 Visitors, and several members of Staff. What the service does well:
The Home provides a clean and comfortable environment, where day-to-day focus is centred on the needs of Residents. General observation, review of records, and discussions with Residents/Relatives/Visitors and Staff demonstrated efforts continue to be made to promote positive outcomes for people with complex and challenging physical and mental care needs. At the time of this Inspection individual bedrooms seen were found to be clean, comfortable and personalised. The Home offers a good choice of menu and provides a comprehensive range of activities appropriate to the capabilities and interests of the Residents. Comments made by Residents and Relatives included, …“The staff really help me with my particular disability”, …“I really enjoy the visiting singers”, … “My relative is very happy and well cared for”, … “The Staff are always friendly and kind to us as well” (visitor), … “The meetings we (Residents and Relatives/Visitors) have with the Manager and Staff are very good, and they take notice of what we say”,… The food is very good, we always have a choice”. St Georges Park Care Centre DS0000022275.V320252.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection?
A great deal of innovative, and effective, change has been implemented during the eleven or so months since the appointment of the Manager, Debbie Baron. Previously, all meals were prepared on-site by staff employed by an outside catering provider. This presented some difficulties, not least the restriction on catering staff in responding flexibly and speedily to Residents’ preferences. The management of catering, including menus, is now under the direct control of the Home Manager. Improvement was evidenced through comments to the Inspector by Residents, which included:- …“The food is very good, and we always have a choice”, …“I love the food”, “…and if I fancy something different I can always have it.” The Manager and Staff have also focussed attention on developing Rydal Unit (Dementia Unit) in order to address specifically the care needs of these Residents. This work has been planned with clinical input from the Department of Psycho-Geriatric Medicine, Stafford University. Examples of such work include: Doors painted in colours which indicate function (e.g. bathroom/toilets are yellow) Introduction of tactile areas to walls Establishment of an indoor garden Introduction of a ‘nursery area’ (small cot, doll), which seeks to develop the memory function of some Residents In addition, bathrooms have been redecorated with the addition of shelving to enable the introduction of plants and decorative objects in order to give a more ‘homely’ feel. New carpets have been ordered for the second floor with fitting to commence 13 December 2006. Implementation of on-going redecoration/refurbishment programme including replacement of armchairs. The Home’s Management has been restructured with the establishment of a Deputy Manager, with Senior Nurse posts having day-to-day operational management responsibility for each Unit. The Manager undertakes monthly audits of service quality by means of an audit tool that covers the areas addressed by National Minimum Standards, and by two further audit tools addressing specifically the kitchen, and the management of medicines. A monthly analysis of findings is forwarded to the Operations Manager at Southern Cross. St Georges Park Care Centre DS0000022275.V320252.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Georges Park Care Centre DS0000022275.V320252.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.V320252.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): 1,2,3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available which should enable prospective Residents (or their ‘agents’) to reach an informed decision about entering the Home. Processes to ensure appropriate and thorough care needs assessment, prior to admission, are effectively applied. EVIDENCE: The Inspector observed the Home’s Statement of Purpose and Service User Guide have been revised so as to be in line with the corporate models utilised by the Home’s new Owners, Southern Cross Health Care. ‘Case Tracking’ involving the review of 6 Residents’ Care Plans/Files, i.e. those relating to the two most recently admitted Residents, plus four selected at random, plus discussion with Residents and Visitors evidenced: Prospective Residents, or their Representatives, are provided with the information needed to make an informed decision as to whether the
St Georges Park Care Centre DS0000022275.V320252.R01.S.doc Version 5.2 Page 10 Home is able to meet their needs and, if necessary, are informed about changes in the cost of their care. All ‘case tracked’ Residents, or their Representatives, had received a copy of their Service Provision Contract, and, where necessary, had been informed in writing of any changes in that Contract since entering the Home. Processes to ensure appropriate and thorough care needs assessment are effectively applied by the Manager, or her Deputy, prior to admission thus enabling an informed decision regarding the Home’s capability of meeting the individual care needs of each prospective Resident. St Georges Park Care Centre DS0000022275.V320252.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): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The model of Care Plan utilised by the Home is of a comprehensive design, easy to read, and up-to-date. The care provided by the Home is effective in meeting the Residents’ assessed care needs, and is delivered considerately and effectively. Residents are treated with respect, their privacy and dignity upheld. The storage, administration, and disposal of medicines are in accordance with accepted good practice. St Georges Park Care Centre DS0000022275.V320252.R01.S.doc Version 5.2 Page 12 EVIDENCE: Care Plans/Files relating to ‘Case Tracked’ Residents were reviewed, discussions held with the respective Residents, Visitors, the Manager and other Staff, plus observation by the Inspector. A ‘Requirement’ cited at the previous Inspection was:“The process of transferring all Care Plan data from the ‘old’ care plan model to the ‘new’ one must be completed without undue delay.” Care Plans reviewed by the Inspector all utilised the ‘Southern Cross’ corporate model. They were found to be current and easy to follow; provided evidence of involvement of the Resident, Relative or Advocate; made direct reference to ‘risk assessment in respect of ‘moving and handling’, use of bedrails, nutritional status/needs, pressure areas. There was evidence of regular audit of care plans by the Manager. This ‘Requirement’ has been met. A review was undertaken of the policies/procedures relating to the management/administration of medicines, i.e. records relating to the supply, storage, and disposal of medicines (including records of ambient and medicine refrigerator temperatures), the maintenance of medicine administration records (MAR Sheets), and the maintenance of the Controlled Drugs Register. The Inspector also reviewed the contents of the medicine trolleys, secondary back-up storage and storage of medical gases. All were found to be satisfactory. In addition, since the previous Inspection, in accordance with Southern Cross Company Policy, the Manager and Staff have reviewed the use of bedrails. This resulted in the issuing of a revised Policy/Procedure relating to this area and the introduction of a different model of ‘cot-side’/’bumper’. Staff records, and conversations with Staff provided evidence that relevant training has taken place. St Georges Park Care Centre DS0000022275.V320252.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): 12,13,14,15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Leisure opportunities are provided consistent with Residents’ capabilities. The Home facilitates achievement of desired social, religious, cultural lifestyle through Residents conducting the pattern of their day as they wish, including contact with family and friends, and continuation of religious practices. There is a daily choice of attractive and nutritious meals. EVIDENCE: The Home has a full and varied programme of activities, which are planned and organised jointly by Residents and Staff under the leadership of an ‘Activities Co-ordinator’, employed for 30 hours per week who attends the Home between 11.00am and 6.00pm. Minutes of Residents’ Meetings, together with comments made by Residents and Relatives/Visitors, provided evidence of their input in determining the range and nature of activities. Evidence was observed showing Residents’/Relatives’ Meetings are held during the afternoons, in addition to the evening, in order to facilitate attendance by interested parties. In addition, there are active links with local clergy representing a number of denominations, i.e. Church of England, the Roman
St Georges Park Care Centre DS0000022275.V320252.R01.S.doc Version 5.2 Page 14 Catholic Church, Seventh Day Adventist, with Residents being escorted to the local Church of England Church by Staff members or members of the Church. Activities include local trips out with Relatives and/or Staff, regular visits to local garden centres, involvement in national commemorative events, traditional games, including cards, dominoes, and bingo, a ‘fitness club’ involving ‘musical movement’ (incorporating input by a physiotherapist), and visiting entertainers/sing-alongs (this includes provision of an ‘in-house produced’ large-print songbook. Currently the Home is planning a trip to see the Pantomime (‘Peter Pan’) at the Oakengates Theatre. Of particular note, and to be commended, is the effort being made to engage Residents with dementia in appropriate activities. This is reflected in the 1:1 sessions with the Activities Coordinator, evidence of which was seen set in the weekly activities programme and confirmed by Residents and Relatives. Previously, all meals were prepared on-site by staff employed by an outside catering provider. This presented some difficulties not least the restriction on catering staff in responding flexibly and speedily to Residents’ preferences. The management of catering, including menus, is now under the direct control of the Home Manager. Improvement is evidenced, through comments to the Inspector by Residents, which included; “The food is very good, and we always have a choice”, “I love the food”, “…and if I fancy something different I can always have it.” St Georges Park Care Centre DS0000022275.V320252.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): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The interests of Residents are protected through ready access to information relating to advocacy services and the Home’s Complaints Procedure. Staff are aware of their role in protecting Residents from abuse. EVIDENCE: A clear and concise Complaints Procedure is displayed in the main hallway, which includes reference to the Commission for Social Care Inspection as the regulatory body, together with contact details. It was very evident the open and inclusive approach of the new Manager, reflected by the ‘open door policy’, in addition to a ‘Manager’s Surgery’, intended for Relatives and advertised in the Monthly in-house Newsletter, is greatly appreciated by Residents and their Relatives/Visitors. The Inspector was informed they found the Manager to be available and approachable, very communicative and responsive to any issues they felt the need to raise. The Home maintains a record of complaints, which was observed to be current. Residents stated they would have no hesitation in raising matters if they had any concerns, and were confident these would be dealt with promptly. Policies relating to protection of Residents from abuse were observed to be in place and readily accessible, including ‘Whistle Blowing’, ‘Abuse Awareness’ and ‘Adult Protection’. Staff training files indicated that Staff had received training in respect of these Policies.
St Georges Park Care Centre DS0000022275.V320252.R01.S.doc Version 5.2 Page 16 Complaints Procedure details are included in the Service User Guide and are displayed prominently for the benefit of all interested parties. Examination of ‘Accidents/Incidents’ Records demonstrated nothing of particular concern for the Inspector. During recent months four ‘Concerns’ and two ‘Complaints’ have been lodged with CSCI. All but one related to the same issue, i.e. the nursing of Residents on mattresses placed on the floor. On investigation it was found that for a period of a few weeks the Home, in conjunction with all other Homes in the Southern Cross Group, had suspended use of cot-sides pending an internal inquiry into safety of this equipment. This interim action, taken to prevent injury to Residents who were assessed as needing cot-sides, resulted in nursing those Residents on mattresses on the floor of their bedrooms. Prior to this action the Home undertook consultation with all Residents, capable of direct involvement, and with Relatives of all Residents involved. The Inspector observed evidence of this including signed agreements. One of the complaints made involved a visitor, who was unaware that another close relative had been consulted, and had signed agreement to the action taken. Complaints records showed the Home had dealt actively with concerns/complaints made known to the Manager. The CSCI Inspection Record also showed the Home had responded speedily in explaining to the CSCI what action had been taken and the reasons why. In the meantime, Southern Cross has invested heavily in new beds with better/safer cot-sides/buffered-bedrail arrangements. The Inspector observed these to be in use and it was evidenced all Staff have received training in the use of the replacement equipment. St Georges Park Care Centre DS0000022275.V320252.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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home provides a generally safe environment with communal rooms, and many bedrooms, benefiting from a recently commenced redecoration and refurbishment programme and the replacement of armchairs. The gardens are easily accessible at all times of year. General cleanliness throughout the Home is good. EVIDENCE: A ‘Requirement’ cited at the previous Inspection was: “A programme of routine maintenance and renewal of the fabric and decoration of the premises is produced and implemented with records kept.” The Home now has a redecoration/refurbishment programme, which is on-going. The Inspector was able to observe progress made to date during the tour of the Home and through reviewing related records.
St Georges Park Care Centre DS0000022275.V320252.R01.S.doc Version 5.2 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is generally good. This judgement has been made using available evidence including a visit to this service. Staff numbers on duty and skill-mix were sufficient to meet the assessed care needs of current Residents. Recruitment and employment practices are consistent with the safeguarding of Residents. The commitment of the Home in providing training for Care Staff, which was previously questionable, is now good and in accordance with individual Staff Members’ learning needs. EVIDENCE: The current staffing rota, and those from the immediately preceding weeks, were examined. Staffing numbers and skill-mix enable a service provision, which meets the care needs of the Service Users. Staff Personal Files demonstrated evidence of full compliance with employment practice aimed at ensuring the safety of residents. Staff are subject to a thorough, and relevant, orientation/ induction programme, which is followed by comprehensive ‘foundation’ training, e.g. ‘manual handling and lifting’, ‘fire safety’, ‘simple infection control’. However, the Home currently falls short of the ‘Standard’ relating to the proportion of Care Staff who have attained NVQ Level 2 or higher. Specifically, 11 out of 43 Care Assistants have NVQ Level 2; 1 has NVQ Level 3. Staff
St Georges Park Care Centre DS0000022275.V320252.R01.S.doc Version 5.2 Page 19 training files provided evidence that 5 Care Assistants are ‘on-target’ to attain Level 2 NVQ during December 2006, with a further 5 completing by March/April 2007. In addition, 10 Care Staff with Level 2 are expected to complete Level 3 studies by March/April 2007. Given the previous low number of Care Staff with NVQ Level 2, progress made since the appointment of the new Manager, shows commitment, and effort in encouraging and enabling staff development. It is expected that by the time of the next inspection the target of 50 of Care Staff having attained NVQ Level 2 will have been achieved and the ‘Standard’ met. St Georges Park Care Centre DS0000022275.V320252.R01.S.doc Version 5.2 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home is well managed by Debbie Baron who has actively, and effectively, addressed issues previously unattended. Operationally, the Home now appears well organised with the central purpose being ‘the best interests of Residents’ with an ambience that is warm, friendly and inclusive. Lines of accountability are clearly defined and observed. The views of Residents and other interested parties are regularly sought by the Home and acted upon. Service Users are safeguarded by the financial procedures operated in the Home. All Staff are subject to effective support with regular supervision, and appeared involved and happy in their work. Health and Safety Policies/Procedures/ Practices were satisfactory. EVIDENCE:
St Georges Park Care Centre DS0000022275.V320252.R01.S.doc Version 5.2 Page 21 The Manager is to commence the Registered Manager Award during December. Observation by the Inspector, together with comments from Residents, Visitors and Staff, suggest the Home is currently being well managed with clear signs of improvement in many areas of care provision. Since taking up post in January 2006 it is evident the Manager has made a very positive impact on the quality of care provided by the Home. Good support is provided by regular attendance at the Home by the Operations Manager (Southern Cross Health Care) as evidenced by monthly submission to CSCI of Regulation 26 Visits. Records reviewed demonstrated monies held by the Home on behalf of Service Users is being managed appropriately, e.g. there are full records of transactions, including receipts and two signatures where necessary. Quality assurance work, including questionnaires to Residents and regular meetings with Residents, Relatives/Visitors has increased. Results of these questionnaires, and notes of monthly meetings, were observed and found to be relevant with suggestions being implemented where possible. COSHH requirements were satisfactory, with maintenance and servicing of equipment regularly undertaken, and appropriately documented. Records are maintained for hot water supply to baths, and water temperatures tested during the Inspection were satisfactory. COSHH data sheets were up-to-date. St Georges Park Care Centre DS0000022275.V320252.R01.S.doc Version 5.2 Page 22 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 3 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 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 3 X 3 St Georges Park Care Centre DS0000022275.V320252.R01.S.doc Version 5.2 Page 23 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. 1. 2. Standard OP28 OP31 Regulation 18. (1)(a) 9. – (1)(2) Requirement A minimum ratio of 50 Care Staff must have achieved NVQ Level 2. The Manager must make formal application to the CSCI for Registration as Manager of the Home. This is to be implemented without further delay. Timescale for action 30/04/07 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Georges Park Care Centre DS0000022275.V320252.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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
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