Inspection on 07/12/05 for St Mary`s Mount

This inspection was carried out on 7th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

Other inspections for this house

St Mary`s Mount 09/04/08

St Mary`s Mount 18/10/07

St Mary`s Mount 29/06/07

St Mary`s Mount 14/06/06

St Mary`s Mount 18/05/05

St Mary`s Mount 18/01/05

St Mary`s Mount 29/11/04

St Mary`s Mount 26/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Mary`s Mount Holly Road Uttoxeter Staffordshire ST14 7DX Lead Inspector Sue Jordan Announced Inspection 7th December 2005 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 Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 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 Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Mary`s Mount Address Holly Road Uttoxeter Staffordshire ST14 7DX 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) 01889 562020 01889 562020 HAS Careplus Limited Mrs Elizabeth Smith Care Home 30 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (7) St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18/05/05 Brief Description of the Service: St. Marys Mount stands in its own grounds where the local Social Service Day Centre is also to be found. It is located within half a mile of the centre of Uttoxeter where a wide range of local shops and services can be accessed. There is a town bus route passing the gateway, and the railway station is about a mile away on the other side of the town centre. Access to the upper residential floor is either by stairs, or by a shaft lift. There were 19 residents in the home at the time of the inspection. The dependency level of residents is varied and fluctuating. There are two adjoining lounges and a separate dining room that can also be used as a quiet area. There is a small sitting area in the inner hallway. There are 28 bedrooms, 26 of which are for single occupation, and two of which are shared. There are no rooms with en-suite facilities at the current time. A separate smoking area for residents has been created. St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced Inspection took place over seven hours and the methodology used were a tour of the environment, discussions and lunch with residents, observations of medication administration and staff/service user interaction. Pertinent records were checked including care plans and staff recruitment files. The inspection was undertaken by the Lead Inspector for St Mary’s Mount and a locum inspector on induction. What the service does well: What has improved since the last inspection? Generally care planning continues to improve with regards to the amount of information available. The manager is presently obtaining the wishes of residents and/or their families with regard to death and dying. Improvements to the environment continue. These include new flooring in some of the bathrooms, the covering of more radiators and locks have been fitted to the bedroom doors. The manager and staff have decorated the lounge area, which is vastly improved. Staff recruitment and training continues to progress with minor improvements required to fully protect the residents. St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 6 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 Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5, 6 The needs of the residents are assessed prior to entering the Home ensuring that their needs can be met. The Home does not advertise that there is opportunity for them to visit for trial periods and although a contract has been developed, it had not been implemented for the privately funded residents at the time of this visit. Addressing this will enable potential residents to make a more informed choice. EVIDENCE: A copy of the recent Statement of Purpose was available. Amendments as recommended at the last inspection have been made. It was noted that the admissions procedure had been missed out, although a policy is available in The Home. However this means that the trial visits verbally offered to potential residents are not advertised. There are presently only two residents paying for their own care. The Home was advised that they must implement the developed contracts between them and the residents. St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 9 The care records for the most recent admission were checked. The manager received a Care Management assessment and care plan prior to admission. Care plans have been developed using this information. The Home does not provide intermediate care. St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Care planning continues to improve and staff have access to this information, assuring that they know how needs are to be met. The service users are enabled to have health professional advice and assistance as required. To further afford the safety of the residents the medication procedures require strengthening and care practices require examination to ensure the privacy and dignity of individual residents. EVIDENCE: Generally care planning continues to improve. The staff are signing their understanding and compliance and individual weight charts have been added. The manager is aware that individual risk assessments must be undertaken and she has received the appropriate training. The care plans have recently been reviewed; however there had been a gap of six months. These should be undertaken every month. There is evidence within the care records that medical health services are accessed, for the residents as required. St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 11 A number of deficiencies were identified regarding the medication procedures: • • • • • • Residents should only receive medication prescribed specifically for them. Staff must check the label on the medication and ensure that it is prescribed for the person receiving it. A list is required of staff names, their full signatures and method of initialling. It is recommended that the date of opening be written on all liquid preparations and creams. The Home’s homely remedies protocol contains valuable information, however there is no evidence that the individual use of such medication has been approved by their general practitioner. It is recommended that eye drops be administered in a private and dignified manner. Staff should wash their hands prior to administration. Medication stock control must be closely monitored. Staff responsible for administering medication are trained by one of the proprietors, a pharmacist. It is recommended that this be refreshed and supported by the ‘Safe Handling of Medicines’ course. Lunch was shared with the residents and as a result, issues regarding privacy, dignity and choice were discussed. The manager needs to investigate how individual dignity can be upheld. It is noted however that locks have been fitted to the bedroom doors and lockable storage provided, promoting privacy for those that wish it. A shower and double toilet area could compromise privacy and dignity for the residents. The manager reported that, to the best of her knowledge, at no time would more than one resident use this area at any given time. In order that this is further assured the manager was asked to develop a strict protocol, which instructs staff that this area must be used by one resident at a time only. It is recommended that future environmental improvements include work to individualise this area. The manager has started to obtain information from residents and/or their families regarding their wishes for death and dying. This information should be included in the care records. St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Community links are being forged with a local school and Christmas entertainment is being planned. Friends and families are made welcome in The Home. The manager must explore how The Home can offer more individual choices to the residents. EVIDENCE: On the day of this visit, children from the local school were entertaining the residents with a recorder recital. Links are being forged with the school and some residents have been for lunch and others are going to a nativity play. A number of Christmas entertainers have been arranged. The daily activities continue to be ad-hock and depend on the number of staff on duty. It is still recommended that the senior staff member responsible for organising activities access training to further develop her skills in this area and that she be given specific allocated time for structured and more regular activities. The manager is trying to access training for this member of staff and it is hoped that extra staff will soon be available. Friends and families are made welcome in The Home. St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 13 Lunch was shared with the residents and as a result, issues regarding choice, privacy and dignity were discussed. This included the provision of a choice of drinks and whether it is necessary that all residents have a plastic beaker. Assistance should be provided in a quiet, dignified manner, which does not advertise residents’ difficulties. The manager must explore how The Home can offer more individual choices to the residents; for example, a choice of drinks and whether sauces and gravies could be provided independently. The meal itself was good quality, however the setting, utensils provided including crockery, furniture and some of the care practices do not ensure a dignified, pleasant meal time for all of the residents. St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 Complaints are addressed appropriately and the Protection of Vulnerable Adults procedures and recruitment checks protect the service users. EVIDENCE: The complaints procedure is appropriate and there have been no complaints to The Home recently. A former complaint was investigated and the action recorded adequately. The residents’ right to a political vote has been maintained via postal vote. Protection of Vulnerable Adults and Criminal Records Bureau checks are obtained for potential members of staff and training is provided to staff. St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 15 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, 20, 21, 24, 25, 26 Environmental improvements continue to made to the Home, however more are required to improve both the domesticity and comfort, whilst maintaining the safety. EVIDENCE: A tour of the Home was undertaken. The care manager and staff have recently decorated the lounge and hung new curtains creating a cosy environment, which is a major improvement. Door locks have been fitted to the bedroom doors, lockable storage has been provided in all of the bedrooms and most of the radiators and pipes have been covered. New flooring has been fitted to the lounge and some of the bathroom/toilet floors. It is recognised that since purchasing the property the present proprietors have made many improvements. St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 16 A number of areas remain outstanding: • • • Following advice from infection control nurses, the Home is to have a separate sluice area fitted. Many areas of the Home require re-decoration, including the dining room. Although many new items of furniture have been purchased in the last twelve months, some of the existing furniture and fittings are old and inadequate in places, including the dining room and some bedrooms. It is recommended that The Home get rid of the old ‘hospital type’ lockers and the dining room furniture is desperately in need of replacement. It is old, broken and ripped in places. Most of the chairs do not have arms and the needs of the residents should be considered. Light fittings are not fitted with lampshades. Many of the bedrooms do not contain the required elements of furniture and require re-decoration. • Further issues were discussed at this visit: • The door to the new smoking room was wedged open. This was removed, as required immediately. In order that the residents have free access, it is advised that a magnetic catch, linked to the fire safety system, be attached. Two pieces of vinyl flooring had been placed on the smoking room floor; they were removed due to being considered a trip and fire hazard. (An immediate requirement was left). • The hot water temperatures were variable in the building. The temperature of the water in the downstairs bathroom exceeded 50 degrees Celsius. Upstairs the water temperature was only 32 degrees. The manager was asked to ensure a safe bathing protocol until the situation is rectified. It was promised that this would be done on 08/12/05. (An immediate requirement was left). • The laundry floor must be made safe by the refitting of the strip to the steps. (An immediate requirement was left). • A downstairs fire door is sticking. • The crockery provided for service users’ use, are old and mismatched. • A shower and double toilet area could compromise privacy and dignity for the residents. The manager reported that, to the best of her knowledge, at no time would more than one resident use this area at any given time. In order that this is further assured the manager was asked to develop a strict protocol, which instructs staff that this area must be used by one resident at a time only. It is recommended that future environmental improvements include work to individualise this area. • An upstairs bathroom contains a bath unused by the residents. This is due to the fact that there is no bath chair and that the residents are unable to climb in. • A trip hazard was found upstairs in a hallway. The manager said that the maintenance man was aware. St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 17 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 Staff recruitment and training continues to progress with minor improvements required to fully protect the residents. EVIDENCE: The staffing ratios are adequate for the present number of service users. 47 of the staff team have NVQ qualifications. The recruitment records for the most recent member of staff were checked. Most elements were present, except proof of identity. The manager was advised that she should check whether application forms are completed properly, including any gaps in employment. The training records were checked. Generally, major improvements have been made to the provision and opportunities in training during the last twelve months. There are however still some gaps in mandatory training requirements, which includes food and hygiene. 30 of the staff team need to undertake fire safety instruction. St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 18 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): 33, 36, 38 The manager is required to introduce a robust monitoring system to audit the quality and the safety of the service provided. An effective staff supervision system will assist this process. EVIDENCE: The proprietors have put together a Quality Assurance file, which evidences the methods used to audit the quality of the service provided at The Home. A discussion was held regarding the effectiveness of questionnaires and that the systems should also include robust monitoring by the management team. This should include care practices and Health and Safety issues. Given the number of concerns raised at this inspection and the inability of some residents to understand a quality questionnaire, a more vigorous monitoring system should be developed and implemented. St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 19 The manager has started to introduce the staff to supervision, however she is aware that more evidence is required. The day staff have not have a team meeting and individual appraisals have not been carried out. Some of the issues identified during this inspection highlight the need for more effective and productive staff supervision. A number of environmental Health and Safety concerns were raised during this visit, which have resulted in four immediate and a number of subsequent requirements being made or carried over. Detail of these is provided in the Environmental section. In particular two recent accidents have resulted in a requirement being made that the manager undertake an analysis of these incidents. This should consider why the accidents occurred, what could have been done to prevent them & the action to be taken to prevent future accidents of this nature. It is also advised that the monthly Health and Safety audits should include the manager and that more emphasis be placed on assessing and preventing the hazards. St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 20 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 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X 2 X X 2 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 2 X 2 St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 21 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 OP2 OP7 Regulation 5 (1b, c) 15 Requirement Contracts must be implemented for any resident purchasing their own care. Care plans must contain assessments of individual resident risk. Care plans must be reviewed monthly. Medication procedures in The Home must be robust and comply with The British Pharmaceutical Guidelines. Timescale for action 01/02/06 01/02/06 3 OP9 13 (2) 01/01/06 4 OP10 12 (4a) The registered person shall make 16/12/05 suitable arrangements to ensure that The Home is conducted in a manner, which respects the privacy and dignity of the residents. The manager must develop a strict protocol, which instructs staff that the downstairs shower and toilet area must be used by one resident at a time only. The manager must, where possible, obtain information from residents and/or their families DS0000005003.V260339.R01.S.doc 5 OP10 12 (4a) 01/01/06 6 OP11 12 (2, 3) 01/03/06 St Mary`s Mount Version 5.0 Page 22 regarding their wishes for death and dying. 7 OP14 12 (2, 3, 4b,) The manager must explore how The Home can offer more individual choices to the residents. The Home must address the fire safety concerns identified within this report, including fire doors. Immediate Requirement The Home should be equipped with furniture, which meets the needs of the residents and be reasonably decorated. The Home must maintain the appropriate ratio of usable bathrooms. The Home must provide adequate furniture, fittings & other furnishings in the service user bedrooms. The manager must undertake individual risk assessments to support any decisions not to provide that resident with a key to their bedroom. Water temperatures must be close to 43 degrees Celsius. Immediate Requirement Radiators and pipe work should be covered in the Home. Previous requirement Sluice facilities must be provided. Previous Requirement Hand washing facilities must be available in the laundry area. DS0000005003.V260339.R01.S.doc 16/12/05 8 OP19 23 (4) 08/12/05 9 OP19 23 (2a, b, d) 01/06/06 10 OP21 23 (2j) 01/01/06 11 OP24 16 (2c) 01/03/06 12 OP24 12 (1a, 4a) 01/01/06 13 OP25 13 (4) 23 (2j) 23(2p),13 (4a,c) 23(2k)13( 3) 16(2j)13( 3) 08/12/05 14 OP25 01/03/06 15 OP26 01/04/06 16 OP26 01/04/06 St Mary`s Mount Version 5.0 Page 23 17 OP29 19(1a-c)2 Previous Requirement Information and documents in respect of staff working in the care home be maintained as specified in Schedule 2. Previous Requirement Food and hygiene training must be provided at the appropriate frequencies. The Quality Assurance systems must be strengthened to ensure more robust monitoring of the care practices in The Home. Evidence is required that staff receive effective supervision. The Health and Safety in the Home must be given higher priority, including regular assessment of risk and the subsequent appropriate action taken. 01/01/06 18 OP30 18 (1ci) 01/02/06 19 OP33 24 (1a, b) 01/01/06 20 21 OP36 OP37 18 (2) 13(4a-c) 16/12/05 16/12/05 22 OP37 13 (4, 5) 12 (2) Previous Requirement The manager must undertake an 16/12/05 analysis of the recent wheelchair accidents. This should consider why the accidents occurred, what could have been done to prevent them & the action to be taken to prevent future accidents of this nature. Immediate Requirement St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 24 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 OP9 OP9 OP12 Good Practice Recommendations It is recommended that staff medication training be refreshed as soon as possible. It is recommended that the staff undertake the ‘Safe Handling of Medicines’ training. It is recommended that the senior staff member responsible for organising activities access training to further develop her skills in this area and that she be given specific allocated time for structured and more regular activities. It is recommended that future environmental improvements include work to individualise the downstairs shower and toilets area. It is recommended that an audit of the bedroom furniture be carried out to see what is available and what is still needed to meet National Minimum Standard 24. The manager is recommended that she should check whether application forms are completed properly, including any gaps in employment. The manager is advised that she should be included in the monthly Health and Safety audits. 4 OP21 5 6 7 OP24 OP29 OP37 St Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Mary`s Mount DS0000005003.V260339.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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