Inspection on 16/01/08 for St Michael`s Manor

This inspection was carried out on 16th January 2008.

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

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 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 12/10/05

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 Michael`s Manor Woolton Road Woolton Liverpool Merseyside L25 7UW Lead Inspector Jeanette Fielding Key Unannounced Inspection 16th January 2008 10:15 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 Michael`s Manor DS0000025418.V352849.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 Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Michael`s Manor Address Woolton Road Woolton Liverpool Merseyside L25 7UW 0151 427 9419 0151 427 9421 office@springwood.fsworld.co.uk 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) M.E.S. Pension Fund Mr Philip Sergeant Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 44 Nursing Care and 44 Personal Care within the overall number of 44 44 Nursing or 44 Personal Care of which 5 may be used for terminally ill (older people) (TI/E) One service user under 65 years of age requiring terminally ill care may be admitted within the overall number of 5 TI(E) 21st September 2007 Date of last inspection 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. A private company owns both homes. St Michaels Manor is registered both for residential and nursing 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. Passenger lifts and stairs serve the upper floor. Accommodation for residents is provided in single rooms many of which have en-suite facilities. 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. The fees for the home range from £290.00 to £423 per week which includes a top up fee of £17.50. St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This unannounced inspection was conducted by Mrs J Fielding and Miss J King and was undertaken in one day over a period of six and a half hours. As part of the inspection process, all areas of the home were viewed including many of the service users bedrooms. Assessments and care plans were inspected together with staff records and certification to ensure that health and safety legislation was complied with. Discussion took place with the registered manager, nurses, care staff, service users and visitors to the home. A preinspection questionnaire was sent to the home to provide inspectors with information regarding staff, service users and the premises. The manager had not completed this and so additional time was spent during the inspection gathering information. What the service does well: What has improved since the last inspection? What they could do better: There remains a lack of evidence of training given to staff which also includes induction training. The staff files do not contain all necessary information as required. Health and safety issues need to be addressed as a priority as some outstanding issues still present as a risk to both staff and service users. The programme of redecoration and refurbishment needs to ensure that service users bedrooms are addressed to provide a pleasant and homely environment. Medications are not dealt with appropriately to ensure that service users are protected. It is necessary for staff who handle medications are given updated St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 6 training and their competency assessed. The manager did not complete the pre-inspection documentation that was sent prior to the inspection. 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 Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 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 Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information recorded in the assessment forms lacks some necessary detail to enable the home to demonstrate that they can meet service users needs and has the potential for impacting on the level of care given. EVIDENCE: The Statement of Purpose and Service User Guide have not been changed since the last inspection as they contain full information regarding the services and facilities provided by the home to assist prospective service users in deciding whether the home can meet their needs. The assessments for three service users who had recently been admitted to the home were inspected. One assessment was found to contain errors and misspellings that have resulted in incorrect information being recorded at the St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 9 time of the assessment. There is the risk that the information recorded at the time of the assessment may impact on the level of care being given to the service user. The manager should regularly audit the documentation completed by staff as part of his supervisory role to ensure that staff training needs are identified. Discussion with staff identified that the assessment forms held on service users files were completed at the time of the service users admission to the home. The pre admission assessments were requested from the nurses who explained that these were held in the manager’s office. They were requested from the manager who stated that they were held by the nursing staff. The original, completed assessment forms were therefore not inspected. A full inspection of all pre admission assessments will be undertaken at the next inspection to ensure that the care, health and social care needs of service users are fully assessed and that the home can demonstrate that they can meet those needs. The two additional assessments were found to contain basic information about the service users needs. These documents are used to prepare a plan of care for the service users and a review of the format used, and the information recorded should be undertaken. This was raised at the previous inspection but there is not evidence that the documentation has been improved for service users admitted to the home since then. The home does not offer intermediate care. St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is a lack of staff training and understanding of the safe handling of medication and has the potential for placing service users at risk. Care plans lack some of the necessary information regarding service users needs and could place them, and the staff at risk. EVIDENCE: A total of six care plans were inspected. The inspectors were advised that plans were in place for new documentation to be provided for care planning and that these had been ordered. A small number of care files will initially be transferred to the new system to enable the staff to evaluate the effectiveness of these. The file for one service user who was accommodated for palliative care did not contain nutritional assessments or plans. There was no record of this service users weight to give an indication that the nutritional needs were being met. St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 11 This would be essential to ensure that the dietary needs of this service user had been assessed and that those needs were being met. The daily records competed by staff regarding this service user were detailed and provided evidence of the actual care given. One service user was assessed as a high risk of having falls but no management plan was in place to reduce or remove these risks. One service user was accommodated for personal care, but inspection of the care file showed that a high level of input was being provided by nursing staff in the form of observation and monitoring. The service user required the use of an electric bed and a Pentaflex pressure relieving mattress. Consideration should be given to reviewing the care needs of the service user and, if necessary, seeking the advice of the Assessment Team to ensure that the service user is accommodated for the appropriate level of care. The moving and handling information for one service user contained conflicting information. One record stated that two staff would be needed to assist the service user to transfer into a chair, whilst another record stated that only one member of staff would be needed. This has the potential for placing both the service user and the member of staff at risk, particularly as another record stated that the service user was at a high risk of falls. All documentation should be accurate to ensure that service users and staff are protected. Monthly reviews of service users care needs are undertaken but in most instances, the staff are recording ‘no change’. This does not provide details of the review and is not acceptable. Clear records are held on service users files of visits made to and by other healthcare professionals. Details are held of changes to medications and wound management as recommended by these professionals. These changes are recorded in the care plans to advise staff. All medications were inspected. At the last inspection, no problems were identified with the medications, however, at this inspection, it was evident that staff are not following the home’s policy and procedure which has the potential for placing service users at risk. The home’s policy and procedure was not available in the medication room and the only information available for staff was an outdated Liverpool Health Authority document. The Medication Administration Record sheets (MARs) had not been completed appropriately. Hand written entries did not identify the amount of the medication provided by the dispensing pharmacist and so it was not possible to audit the medications accurately. No evidence had been given, in the form of signatures next to the handwritten entries, to demonstrate that the entries were accurate and that this had been witnessed. Some blank spaces were St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 12 noted on the MAR sheets where staff had failed to sign to indicate that medications had been administered to service users. One medication, held in the refrigerator, was not named and no instructions held for the administration of it. The nurse in charge said that she was not sure which service user it was for. The container for the disposal of medications was not securely stored and the records of these medications were not complete. Medications that service users refuse to take had not been placed in the disposal container and no record was held of how the medication had been disposed of. The temperature of the refrigerators for the storage of medications was inaccurate. The records show that the temperature of the refrigerators ranged between 11 and 27OC on all days for the past two weeks. This is not acceptable as excessive temperatures will cause medications to deteriorate. It was of great concern that qualified nurses had continued to record these excessive temperatures and had not identified that there was a problem with the storage facilities. The nurse on duty stated that she would normally deal with all medication issues, but had been on annual leave for two weeks. It is of great concern that qualified nurses and senior care assistants had allowed the safety of service users to be placed at risk through negligence or lack of understanding. It is required that all qualified nurses and senior care staff who are involved with the ordering, storing, administration, recording or disposal of medication, undertake formal training and have their competence assessed and evidence of training and competence recorded on their individual file.. The audit system used for medications has proved to be ineffective and the methodology should be reviewed to ensure that accuracy of all medications is maintained. The inspectors were advised that a new form was being prepared for the use of all medications that are prescribed by doctors and administered on the request of the service user, or at the discression of the nurses, to provide a more effective information base. The form is not yet in use. All service users are accommodated in single bedrooms to promote their dignity and privacy. Staff were observed to knock on bedroom doors prior to entering. St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good level of social activity takes place to provide service users with stimulation and social interaction to enrich their lives. EVIDENCE: On admission service users are asked about their lifestyle, choice of foods and preferences of the social activities they would like to take part in. The service user with help from a family member or staff completes a social questionnaire, which includes schooling, work, hobbies, food likes and dislikes and television and radio preferences. This information is used to form an activities plan. Ministers visit the home on a regular basis and provide communion for the service users. Services take place in the lounge and communion was being given on the day of the inspection. The inspectors spoke at length with one of the ministers who explained that the staff enabled mobile service users to attend. None of the service users who are confined to bed, or to their room are given individual services. Consideration should be given to building on the St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 14 information held about service users and for additional service users to have their spiritual needs met. A programme of activities is arranged for the service users to offer entertainment and stimulation. Service users spoken to during the inspection said that sometimes the days were long and that they looked forward to doing something different than watching television. Staff were observed to spend time with service users on a one to one basis to provide a personal approach to social interactions. Visitors are welcome at the home at any time and service users may meet with their visitors in one of the communal areas or in the privacy of their bedroom as they choose. Service users confirmed this. Visits are usually recorded in the service users care file including visits from clergy and health care professionals. Meals are prepared in the main kitchen and served from heated trolleys in the dining room. The kitchen is clean and organised and a good stock of food is held. It was observed that the meals for service users who choose to eat in their bedroom are transported without covers. It is essential that all foods are covered during transportation to avoid the risk of contamination. The menus provide evidence that a varied and balanced diet is offered and that service users may choose from a selection of meals. Meals are taken in the dining room or in the service users own bedroom as they wish. Dining tables were attractively laid and the meal served on the day of the inspection looked and smelled appetising. Service users said that the meals in the home were very good and that they enjoyed them. Special diets can be provided on the advice of the GP or dietician or on the request of the service users. A new kitchenette has been provided off the dining room and now provides facilities for making drinks and snacks. Staff spoken to said that this kitchenette is small and becomes difficult to work in when a number of staff are making drinks and serving meals at the same time. To ensure safety, the number of staff in this area should be limited at busy times. St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Training on adult protection and of the action to be taken in the event of abuse being suspected is necessary to ensure that all service users are protected. EVIDENCE: The home has a robust complaints procedure which is detailed in the Statement of Purpose and also displayed within the home to inform service users and visitors to the home of how to complain and the person to whom the complaint should be directed. No complaints have been received by the home or by CSCI since the last inspection. Service users spoken to during the inspection were aware that they could speak to the manager if they had any concerns but all said that they were happy with the service provided. The inspectors were advised that staff had been given informal training on adult protection but none of the staff spoken to were fully aware of how to report an allegation of abuse. Some staff have had training around safeguarding adults but others have a limited understanding in this important area. This leads to inconsistent knowledge and practice within the service. It is essential that all staff are given accredited training on adult protection and of the action to be taken in the event of abuse being suspected. St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Work is taking place to improve the standard of home to provide a pleasant environment. Service users and staff remain at risk due to the lack of health and safety interventions. EVIDENCE: Work has commenced to improve the environment for the service users. The main lounge and dining room have been redecorated and are bright and homely. It is evident that some new furnishings have been provided in these areas. The main entrance hall and staircase have been redecorate, together with many of the corridors. This has been a major task due to the extent of the St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 17 area and has dramatically improved the first impression of the home. Plans are in place to replace the carpets in the foyer and on the corridors but this will not take place until the redecoration programme is completed. A new kitchenette has been provided off the main dining room to provide additional facilities for service users, visitors and staff. The bathrooms and toilets on the ground floor near to the foyer were being redecorated at the time of the inspection. Service users were not therefore provided with toilet facilities close to the lounge, although it was expected that this work would be completed within a few days. Redecoration of the bedrooms still remains to be undertaken. A high number of rooms require attention and were highlighted at the previous inspection. Many of these remain outstanding. Room 54. The bed rails fitted to this bed were identified at the last inspection as not being suitable as a pressure relieving mattress had been fitted on the top of the original mattress, resulting in the rails not providing sufficient protection. It was observed that no action had been taken by staff to rectify this risk to the service user and no risk assessment was in place. It is essential that beds are fitted with appropriate bed rails, suited to the type of bed. The advice of an Occupational Therapist should be sought were staff are unaware of how to risk assess or provide adequate protection to the service users. Fire exit. Some improvements have been made to clear this area to make it safe in the event of evacuation of the home, but it was observed that further leaves and debris had accumulated, resulting in the egress from the home becoming slippery and presenting as a risk. The following issues were highlighted at the last inspection and remain outstanding. Rooms 3, 4, 6, 7, 8, 9, 12,13, 19, 40, 41, 42, 44, 58 have not yet had their stained and worn carpets replaced. Room 43. The armchair in this room remains worn stained and damaged. Room 48. The tripping hazard at the entrance to this room has not been made safe. Bathroom by room 4. The bath seat requires to be thoroughly cleaned. The flooring is lifting and presents as a tripping hazard. Bathroom 56. The water from the hot tap remains excessively hot and presents as a scalding risk. The bath seat still requires a thorough cleaning. St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 18 Rear stairwell. The wall is damaged and requires repair and redecoration. The manager stated that the work will take some time to complete and that service users and their relatives are currently being consulted regarding colour schemes for their rooms. No written plan is held in the home to provide the manager with a timescale for the work to enable him to plan for any potential disruption within the home. It is of great concern that some minor maintenance issues, i.e. tripping hazards at the entrances to bedrooms, have not been addressed. These hazards have the potential for placing service users and staff at risk. Bars of soap continue to be used at communal washbasins, increasing the risk of cross infection. It was evident that the housekeeping staff were working hard to maintain a good standard of cleanliness during the redecoration process. Risk assessments should be undertaken in areas where redecoration of corridors is taking place as a high number of tripping hazards were identified, presenting as a risk to both service users and staff. St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff induction training is inadequate and does not ensure staff have the knowledge to provide the care and support to service users and to meet their needs. EVIDENCE: Rotas indicate that there are sufficient trained nurses, senior care staff and health care workers on duty throughout the day and night. There are separate domestic and kitchen staff and the home employs a handyman and an administrator. Service users said that they were happy that the staff met their needs in a timely manner but the inspectors observed one service user who requested her Zimmer frame and had to wait twenty minutes for staff to provide it. The home has a policy and procedure to be followed for the recruitment of staff but inspection of the staff files showed that this has not been followed. One member of staff who had recently commenced work at the home had only one reference in the file and this was from a relative. This is practice does not ensure that service users are protected. St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 20 There was no evidence on the staff files of an effective induction training programme. No evidence was found of staff training on the files. Individually or as a group, the home is unable to provide evidence that staff have the necessary skills to meet the assessed needs of service users. Records are held of supervision given to nurses and care staff but no records are held for housekeeping staff. Overall, the staff records are poor, with a lack of evidence of training, competency and development. Some references are inadequate and the home is unable to ensure safe practice. St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management system in place is not sufficiently robust to ensure that staff and service users are protected. EVIDENCE: The registered manager is a qualified nurse who has many years experience in managing care services for older people. He is responsible for overseeing the care of the service users and the day to day running of the home. The AQAA was not completed by the manager prior to the inspection as required and resulted in a lack of information being provided to the inspectors. St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 22 The manager confirmed that one of the owners of the home visits on a regular basis but does not complete a visit form to inform the manager, and the other owners, of the findings at the time of the visit. There is no evidence of any quality assurance system being in place to obtain the views and opinions of the staff, service users or relatives. Safety certificates were inspected and the Portable Appliances, Gas and Fire Equipment are now all due to be inspected. Tests are made on the fire detection equipment but there is a lack of evidence that staff have been given training at the frequency recommended by Merseyside Fire Authority. The management of health and safety issues is poor as evidenced by the failure to address issues highlighted at the last inspection. St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X X X X 1 St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 24 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. Standard OP3 Regulation 14 Requirement The registered person must ensure that new service users are admitted only on the basis of a full assessment undertaken by people trained to do so The registered person must ensure that a service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. The registered person must ensure that the worn and dirty carpet fitted to the ground floor corridor is replaced. This remains outstanding from the previous inspection. The registered person must ensure that all staff are given training in the protection of vulnerable adults. This remains outstanding from the previous inspection. The registered person must ensure that all damaged, worn DS0000025418.V352849.R01.S.doc Timescale for action 28/02/08 2. OP7 15 28/02/08 3. OP19 23 28/03/08 4. OP18 13(6) 28/02/08 5. OP19 16 28/03/08 St Michael`s Manor Version 5.2 Page 25 and stained carpets are cleaned or replaced as appropriate. This remains outstanding from the previous inspection. 6. OP19 13(4) The registered person must ensure that all tripping risks are identified and removed. This remains outstanding from the previous inspection. The registered person must ensure that risk assessments are prepared in relation to bed rails and appropriate bed rails fitted. This remains outstanding from the previous inspection. The registered person must ensure that all damaged furniture is replaced. This remains outstanding from the previous inspection. The registered person must ensure that appropriate safety measures are put in place to prevent scalding in baths and showers in accordance with the requirements of the Department of Environmental Protection. This remains outstanding from the previous inspection. The registered person must ensure that all fire exits are cleared. This remains outstanding from the previous inspection. 28/02/08 7. OP19 13(4) 28/02/08 8. OP24 16(2) 28/03/08 9. OP19 13(4) 28/02/08 10. OP19 23(4) 28/02/08 11. OP19 23(2) The registered person must 28/03/08 ensure that all areas of the home are reasonably decorated. This remains outstanding from the previous inspection. The registered person must ensure that staff are given DS0000025418.V352849.R01.S.doc 12. OP30 18(1) 28/03/08 Version 5.2 Page 26 St Michael`s Manor training appropriate to the work they are to perform. This remains outstanding from the previous inspection. 13. OP36 18(2) The registered person must ensure that staff are appropriately supervised. This remains outstanding from the previous inspection. The registered person must ensure that the registered person or their representative completes written reports following monthly inspection visits. This remains outstanding from the previous inspection. The registered person must ensure that effective quality monitoring systems are in place. This remains outstanding from the previous inspection. 28/02/08 14. OP33 26 28/02/08 15. OP33 24 28/02/08 16. OP38 12, 13, 16 The registered person must & 23. ensure that the health, welfare and safety of service users and staff is protected. This remains outstanding from the previous inspection. 28/02/08 St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 27 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. Refer to Standard OP19 OP19 Good Practice Recommendations Thermostatic mixer valves should be fitted to all hot water outlets to avoid the risk of scalding. That liquid soap is provided at all washbasins in communal areas. St Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@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 Michael`s Manor DS0000025418.V352849.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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