Inspection on 12/10/05 for St Michael`s Manor

This inspection was carried out on 12th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

St Michael`s Manor 16/01/08

St Michael`s Manor 21/09/07

St Michael`s Manor 23/11/06

St Michael`s Manor 16/06/06

St Michael`s Manor 24/01/06

St Michael`s Manor 08/09/04

St Michael`s Manor 08/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE St Michaels Manor Woolton Road Woolton Liverpool L25 7UW Lead Inspector John McCabe Unannounced 12 October 2005 14:00 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 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 Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Michaels Manor Address Woolton Road Woolton Liverpool L26 7UW 0151 427 9419 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) M. E. S. Pension Fund Mr Philip Sergeant CRH N 44 Category(ies) of OP - 44 registration, with number of places St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) 44 Nursing Care and 44 Personal Care within the overall number of 44 2) 44 Nursing or 44 Personal Care of which 5 may be used for terminally ill (older people) (TI/E) 3) One service user under 65 years of age requiring terminally ill care may be admitted within the overall number of 5 TI(E) Date of last inspection 8 September 2004 Brief Description of the Service: St Michaels Manor is one of two adjacent care homes situated on the same site in a quiet residential area of South Liverpool. Both homes are owned by a private company. St Michaels Manor is registered both for residential and nursing care plus five beds for pallative care. Trees and grassed areas surround the home which gives a sense of privacy, plus the home has its own gardens, there is a car park to the front of the home. The building itself is an older victorian dwelling which has been modernised inside whilst keeping many of the attractive original features such as the ornate ceilings and a sweeping central staircase. The upper floor is served by passenger lifts and stairs. Accomodation for residents is provided in single rooms many of which have a toilet and hand wash basin. The home is centrally heated. There is a large central lounge dining room. The home is close to public transport, rail and bus and is near to the M62 and M57 motorways. . St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection began at 1400 hours on the 12/10/05 with the registered manager of the home. Documents for residents and staff were reviewed, and a full inspection of the building took place, which included bedrooms, laundry, kitchen and the garden areas. Residents staff and were spoken to during the inspection period, to get their views on the conduct of the home. The home was not a clean as it should be as there was only one member of the domestic staff on duty. What the service does well: What has improved since the last inspection? What they could do better: The administration and documentation relating to the training of overseas nurses needs to conform to the regulations of the Nursing Midwifery Council (NMC) and the Department of health (DOH). This was legal requirement in September 2004, which has still not been met. No one should be employed in the home without an enhanced CRB/POVA certificate, or a POVA First clearance. The water flooding in the kitchen, and the lack of hot water in residents’ bedrooms needs to be put right. At each inspection the water temperatures in St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 Page 6 most rooms are cold, a legal requirement was made to rectify the situation in September 2004 and has still not been met. Documented supervision of staff has not yet commenced even though this was a legal requirement in July 04 and September 2004. 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 Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4,5 The Home’s Statements Purpose is up to date and ensures that the home stays within the category of resident agreed with the commission, and prospective residents have some knowledge of the home before they decide to move in on a permanent basis. EVIDENCE: The Home’s Statements Purpose is up to date and ensures that the home stays within the category of resident agreed with the commission, and prospective residents have some knowledge of the home before they decide to move in on a permanent basis. All residents before they move into the home have pre admissionnursing/residential assessment. The importance of the document is to assess the care needs of the resident and to ensure the home has the skill mix of staff to care for the resident. The pre-admission nursing document is the basis of the initial care plan for the resident. Other health care professionals known to the resident are involved in the pre admission assessment. St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 Page 9 Care staff in the home undertakes specialist care training, which is ongoing, to ensure that the assessed and changing care needs of the residents are met. St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10,11. Residents’ individual health, personal and social care needs are clearly recorded. This provides care staff with the information they need to meet the residents care needs. Personal support in the home is offered in such a way as to promote and protect the residents’ privacy, dignity and independence. EVIDENCE: All residents in the home have an individual care plan, which is formulated on admission to the home and is reviewed by the senior nurses on a monthly basis. Daily health records are documented for each resident, this includes any critical incidences plus any visits from GPs, specialist nurses etc. Most of the care staff have undertaken training on tissue viability. The Primary Care Trust (PCT) tissue viability nurse will visit the home at any time if needs arise to address any presenting health care need. Photographic and skin mapping evidence for pressure sores is recorded in the resident’s personal file, so as the healing process of the sore can be checked St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 Page 11 All residents in the home can access their NHS entitlements; which includes access to dentists, opticians, and chiropody services. Care staff will accompany residents for hospital or clinic appointments. GPs visit residents when needs arise. No resident in the home self medicates. All medications for residents are administered by nurses or senior carers in the home. The protocols for the receipt, storage, disposal, and documentation of medications in the home are in accordance with the National Minimum Standards (NMS). However, whilst reviewing the Controlled Drugs Book it was noticed that a resident’s full name was not entered into the book, this is poor practice and could lead to wrong identification of the resident. Residents “Unwanted medications” are recorded by two first level nurses and then taken from the care home by the pharmacy. Residents told the inspector that staff in the home were always courteous, respectful, and maintained their privacy and dignity when doing personal care. Some residents have asked for same gender carers to undertake personal care with them; staff always fulfils this request. St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 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 standard(s) 12,13,14,15. Residents are encouraged to exercise choice and to have flexibility how they spend their day in the home. They also pursue leisure activities according to their choice and preferences. This allows independence and individuality for each resident Residents receive a varied nutritious diet that is in accordance with their preferences. EVIDENCE: Residents in the home are asked on admission, about their lifestyle, choice of foods, and choices and preferences of the social activities they would like to participate in. On admission to the home the resident with help from a family member completes “Social questionnaire, which is a “Work life History” of the resident, and includes schooling, work, hobbies, food likes and dislikes etc. This information is used to facilitate organised activities for the resident. When residents participate in social activities, it must be recorded in their daily health record sheet, how they participated in the activity. This is to ensure that there is recorded evidence of how the resident coped/responded in the activity, and to their mood, emotions, physical dexterity etc. St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 Page 13 The recordings of the resident activities helps to complete a “full picture” of the resident’s progress, or even identify developing care needs. Visitors are allowed in the home at any reasonable time of the day and residents may entertain their visitors in the communal lounges, or in their own bedroom. Residents told the inspector that they enjoyed the variety of food in the home, but sometimes the food was cold especially for those who choose to eat in the bedrooms. Some of the residents prefer to take their meals in their own room rather than go to the dining room therefore the registered manager must remain mindful that the meals in these cicumstances are served hot. The inspector observed the evening meal being served to the residents; the meal was well prepared and well presented. Therapeutic diets can be catered for in the home for residents with a medical condition. St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 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 standard(s) 16,17,18. The home has a satisfactory complaints system, with evidence that residents feel their views are being listened to and acted upon. The homes policy and training programmes for POVA, and Whistle Blowing, ensure that the homes residents are protected from any abuse. EVIDENCE: There have been no internal complaints, and no complaints were reported to the commission since the last inspection. Many of the residents are encouraged to use their postal votes in the local or General Elections. The care home has up to date information on the Protection of Vulnerable adults, this information is communicated to new employees on their induction course. On the day of the inspection there was evidence that many of the staff in the home had undertaken training on POVA protocols, and the Whistle Blowing Policy. However the senior nurse in charge on the evening shift was not aware of the protocols to be followed if there was an allegation of abuse against a resident by a care worker. This should not be the case and action needs to be taken to ensure those staff who have lead responsibility on shift are fully aware of the steps needed to be taken to safeguard residents. St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 Page 15 St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 Page 16 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 standard(s) 19,20,21,22,23,24,25,26, More effort is needed to improve the cleanliness of the home, the decor of a number of rooms, and to ensure that residents have hot water in their bedrooms and bathrooms. At present the comfort and well being of the residents is compromised because of lack of basic maintenance in the home. It is unacceptable that previous requirements in respect of providing adequate hot water have yet to be complied with. Further failure to address statutory requirements may lead to enforcement action. EVIDENCE: On the day of the inspection the home standard of cleanliness was unsatisfactory. The home is large and covers three floors with the accommodation comprising of single bedrooms. The task of maintaining a clean environment is a sizable one for one domestic staff. Therefore the registered person needs to consider having more domestic staff available to maintain a satisfactory level of cleanliness. St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 Page 17 Residents’ hand washbasins in bedrooms on the ground floor had no hot water, neither did the communal washbasins. At the last inspection there was no hot water in the communal bathrooms. This is a breach of regulation and is unacceptable. Action must be taken to address this shortfall as a matter of urgency. The registered person should consider installing a modern water system that can heat water for 45 residents and other services in the home. During an inspection of the kitchen, the entrance to the storeroom was water logged because of what appeared to be an underground water supply leaking in to the room, making it dangerous for staff. The carpet in room 45 needs to be replaced with another suitable floor covering. The lighting in the corridor between rooms 58 and 59 is malfunctioning, and needs repairing to ensure the safety of the residents, staff and visitors. The home’s washing machines in the laundry have had an Eco system fitted to them, this enables soiled washing to be cleaned at lower temperature, using less electricity, soap and water. The washing is ionised and aerated to allow widening of the cloth fibres so soaps can penetrate the fibres and kill more bacteria, including MRSA, Hepatitis B and C. St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30. The standard of vetting and recruitment practices is inadequate with the necessary checks not being carried out on all new staff. This places the residents at potential risk. The present administration and management of the recruitment, training and NMC registration of overseas nurses (O/N) needs to comply with the regulations laid down by the Nursing Midwifery Council and the Department of Health. This is to ensure that overseas nurses are properly prepared and trained before gaining UK 1st Level Nurse qualification. Since the last inspection, management and administration of the O/N has worsened. The manager must ensure that the proper paper work is in place and correct information is included on the work permit information to the home office for the O/N. EVIDENCE: There is always a first level nurse on duty who is assisted by care staff and ancillary staff. It was apparent that some staff have been working in the home for some months without an up to date enhanced CRB/POVA certificate. The manager was not aware of what a POVA First was, or how to access the procedure via the Internet. The inspector informed the manager that it is a significant failure to comply with regulation should staff be employed without the required vetting. Staff St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 Page 19 must not commence employment prior to all of the necessary checks being undertaken. This includes CRB checks at an enhanced level or a POVA first check. The inspector evidenced the Personal Identification Numbers (PINS) of all the registered nurses in the home, which was documented on Nursing Midwifery Council (NMC) stationary. Mandatory and specialist training for all staff is ongoing in the home; this is evidenced in the personal files of the staff. For the past year the home via the registered manager has been recruiting overseas nurses from the African and Asian continent. The nurses are recruited to undertake an Adaptation Course/Supervised Practice to enable them to gain 1st Level Registration i.e. Registered Nurse, with the Nursing Midwifery Council (NMC). The home must comply with the following criteria before they can offer overseas nurse an Adaptation Course/Supervised Practice in the care home. The criteria include: a) The home has an Educational Audit from the local University and is then registered with the NMC. b) The home must have residents who are having nursing care. (Overseas nurses are not placed in residential units whilst undertaking Supervised Practice). c) The registered nurses in the home who act as mentors to the students must have a Teaching/Mentoring certificate. The local university often facilitates this training course). d) The overseas nurse has a confirmation letter form the NMC stating how many months training they have to undertake before they are eligible for registration with the NMC. This letter is valid for two years from the date it was sent to then applicant. The overseas nurse has the required country of origin passport; entry visa and work permit from the Uk authorities. St Michaels Manor is registered via the NMC for two (2) overseas nurses (O/N) at any one time to undertake the Adaptation course. During the course they are regarded as supernumerary and have the duties of a senior carer. St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 Page 20 During case tracking of the O/N documents it was impossible to evidence, Work Permits, Visas, a confirmation letter from the NMC regards their Uk training. It became evident that the O/N were being employed as carers then the manager was then requesting UK work permits for the O/N as Staff Nurses. The manager from St Michael’s Manor, apparently signs the NMC forms for O/N students in another home (St Michael’s Mount), to gain their First Level nurse qualification (RN). O/N in the Manor informed me that they did have some training from the nursing staff in the home, but information to this effect was unable to be evidenced. Some months ago the home recruited O/N in excess of their allowed quota (2) for the Adaptation course. The manager attempted to register more than two students from the Mount and Manor with the NMC and was refused. Some of the O/N students then had to find work in other care homes in the Merseyside area, to complete their adaptation course. This is unacceptable. Since the last inspection, management and administration of the O/N has worsened, with the manager not ensuring the proper paper work is in place and correct information is included on the work permit information to the home office for the O/N. During case tracking, one of the documents reviewed of an O/N stated that the entry visa in to the Uk was for the purpose of being a Student Nurse. The manager was not aware how this student entered the UK and there was no work permit on file. A letter from the NMC could be evidenced in respect of this individual, but it became apparent that the individual had worked, as carer in another care home. As part of the case tracking the inspector rang the initial care home of employment to be told that the person concerned did work there as carer and although they had left the person is still registered with them to undertake bank work for them. In fact the person was scheduled to work a 12 hour shift on night duty (13/10/05). The manager of the Manor claimed he was not aware of this dual role, and in fact the student was to work a 12-hour day on the 14/10/05 directly after completing a 12-hour shift in another care home. This situation is unsatisfactory and clarification must be provided about the employment status of the individuals concerned. The homes manager is fully aware of the rules regulations laid down by the NMC and Department of Health (DOH) on the recruitment and training of overseas nurse and the expectation is that they will comply with them. St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 Page 21 The rules and regulations for overseas nurses and Adaptation course changed on the 1st September 2005. St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36,37,38. Staff morale in the care home is good, resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life. The turnover of care staff is low. However, the registered manager must exercise appropriate control over the checking and vetting of all staff especially in respect of the recruitment and development of over seas nurses and the requirement for staff to have CRB/POVA checks. Continued failure to comply with requirements reflects on the managers ability to fully discharge their responsibilities and may lead to the CSCI considering its use of its powers of enforcement. EVIDENCE: St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 Page 23 An experienced first level nurse manages the home; currently the manager has not registered on an NVQ Level 4 care programme. Previously the manager was in charge of the two homes on the site before the regulations changed. It is concerning to note that the requirement to introduce formal regular supervision in line with the NMS remains outstanding from the last inspection. Documented supervision can ensure that all staff have the opportunity to discuss with the manager, and other senior nurses, any issues, which can effect or improve the care for the residents. Documented supervision of all staff also gives the staff the opportunity to discuss their own /or identified training needs. This will be restated as a requirement. Where possible residents are encouraged to look after their own financial affairs as the home doesn’t hold any bank accounts for individual residents. The homes certificates of insurance and worthiness for machines, gas, electricity, fire equipments, lift, hoists were in date and valid. The Employer’s Liability Insurance certificate is displayed in the main hall of the home and is valid and in date. St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 3 2 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 2 3 3 3 3 2 3 3 St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 Page 25 NO Are there any outstanding requirements from the last inspection? 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. Standard 12 Regulation 12 Requirement The registered person must ensure that when residents participate in organised social activites that it is recorded on their daily health record sheet The registered person must ensure that the cause of the flooding in the kitchen storeroom is repaired to ensure the safety of the staff The registered person must ensure that ceiling light between rooms 58 and 59 is repaired to ensure the safety of residents, staff and visitors. The registered person must ensure there is hot water in residents bedrooms and communal bathrooms The registered person must ensure that the carpet in room 45 is replaced with a suitable floor covering The registered person must ensure that no staff are employed in the home without an up to date enhanced CRB/POVA certificate, or a POVA first certificate The registered person must ensure that the registered F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Timescale for action 31/10/05 2. 19 23 31/10/05 3. 20 23 31/10/05 4. 25 23 31/10/05 5. 24 23 31/10/05 6. 29 19 31/10/05 7. 31 9 31/10/05 Page 26 St Michaels Manor Version 1.30 8. 36 19 manager is informed, knowledgeable and understands the regulations and protocols of the Nursing Midwifery Council (NMC) relating to the training and supervision of overseas nurses in the home, who are undertaking an adaptation course, for eligibility for First Level Nurses registration with the NMC. Previous Timescale of the 30th September 2004 Not Met. The registered person must ensure that all staff employed at the home receive formal documented supervision six times per year. Previous Timescales of the 31st July and 30th September 2004 Not Met. 31/10/05 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 Good Practice Recommendations St Michaels Manor F52_F02_S25418_StMichaelsManor V230557_121005_Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Liverpool Area Office 3rd Floor 10 Duke Street Liverpool, L1 5AS 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. 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