Inspection on 21/09/07 for St Michael`s Manor

This inspection was carried out on 21st September 2007.

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 Michael`s Manor 16/01/08

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 09:30 21 September 2007 st 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.V343523.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.V343523.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.V343523.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) 23rd November 2006 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.V343523.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by Mrs J Fielding and Miss J King and was undertaken in one day over a period of eight 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. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by 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.V343523.R01.S.doc Version 5.2 Page 6 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.V343523.R01.S.doc Version 5.2 Page 7 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 good. This judgement has been made using available evidence including a visit to this service. A comprehensive assessment is undertaken on all prospective service users to identify their needs and to ensure that those needs can be met. EVIDENCE: The Statement of Purpose and Service User Guide contain full information for prospective service users and their families to assist them in deciding whether the home can meet their needs. It is a comprehensive document and contains a wealth of information about the home and its staff, what is included in the fee and what’s not, the management structure, staff training, details of the activities the home provides, photographs of the lounges and bedrooms, details of how to raise a concern or complaints and sample menus. There is a smaller brochure available for people to take away. St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 8 Comprehensive assessments are made on prospective service users prior to their admission to the home to ensure that the home has the ability to meet their individual and specific care needs. The assessments are undertaken by the manager or one of the senior nurses and information is gathered from the service user, their family, the social worker, the long term care team and other multi disciplinary teams as necessary. Information is gathered regarding the service users medical, care and social needs and individual preferences are identified. Sufficient information is gathered to ensure that the home can meet all of the service users individual needs. The assessment provides sufficient information for a plan of care to be prepared. More detailed information is recorded following admission to the home as the service users’ needs change. Prospective service users and their relatives are encouraged to visit the home prior to admission to view the rooms available and to meet other service users and staff. The home does not offer Intermediate Care. St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed care plans are in place and are regularly reviewed to ensure that staff have full information and can give the appropriate level of care and support. EVIDENCE: Individual care plans are prepared for all service users. These are initially prepared from the information gathered at the pre admission assessment and are reviewed and updated on a monthly basis or more frequently as the service users needs change. It is advised that the reviews for service users who are accommodated for palliative care have their care needs reviewed on a more frequent basis. Individual needs are clearly identified and there is evidence of appropriate equipment being obtained i.e. ‘airflow’ mattresses. Risk assessments are prepared and risk management plans are put in place to remove or reduce any potential risk to the service user. The risk assessments varied in detail and quality depending on who had prepared them. Some St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 10 conflicting information was recorded i.e. “unable to weight bear” and “walks with two carers” were found to be recorded on one care plan which had been completed by the same person on the same day. It is essential that accurate information be recorded. It was observed that correction fluid had been used to amend some information which had either been changed or recorded incorrectly. The use of correction fluid is not acceptable. Wounds are well managed with mapping and photographs in place to provide evidence of improvement or deterioration of the wounds. The records also show that referrals are made to the PCT Skin Care Service as necessary. Accurate risk assessments require to be completed for three service users who require the use of overlay pressure relieving mattresses and bed rails. The rails in use were not sufficient to prevent the service users falling from the bed. The rails should be risk assessed and appropriate rails fitted as necessary. It is strongly advised that suitable and sufficient training is provided in the fitting and checking of bed rails. The small palliative care unit is managed by senior nurses with support from G.P.’s specialising in this branch of care. The doctors visit at least twice a week and are “on call” if needed. The home has comprehensive and detailed policies and procedures for the administration of medications. Medications were found to be dealt with by the staff in accordance with the home’s policy and procedure. All records relating to medications were completed accurately and storage areas were clean and organised. Handwritten entries on Medication Administration Record sheets are signed by two members of staff to ensure accuracy of the entries. Regular audits of medications are undertaken to ensure that the home’s safety standards are maintained. It was observed that staff spoke discreetly to service users regarding personal issues to protect their dignity. Staff were observed to knock on bedroom doors prior to entering. All service users are accommodated in single bedrooms, many of which having en-suite facilities. Personal care is given in bedrooms or bathrooms to protect service users privacy and dignity. St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 11 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. Meals are good, offering choice and variety, and cater for resident’s special dietary needs. 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. The social diary is completed most weekdays, albeit very similar information being recorded for some service users e.g. “watched TV in his room today”. Service users said that there were some activities provided but none were observed on the day of inspection. Some service users enjoy services provided by local ministers. The minibus for the home was recently stolen and no arrangements have yet been made for replacement transport to be provided. Service users St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 12 have enjoyed a programme of activities and entertainment and further events are planned. 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. 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. Meals are prepared in the main kitchen. The kitchen was clean and organised although the damaged tiles above the hand basin require repair or replacement to provide a waterproof and hygienic seal. The inspectors were informed that the thermometer had broken and so it was not possible to check the temperature of cooked food. The temperature of the refrigerator and freezer had not been checked for several days. The failure to ensure that food is stored and cooked to the correct temperature has the potential for placing service users at risk. Some outdated dry stock was found and subsequently removed by the cook. Food stocks were good with fresh fruit and vegetables being available. St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a robust complaints procedure to protect service users. 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. Two complaints have been made since the last inspection, one currently being investigated. Records are maintained of the complaints and of the investigation undertaken. Protection of vulnerable adults training is given to staff during the induction process and it is recommended that further training is given to all staff including housekeeping and catering staff. Staff spoken to were aware of the different types of abuse but not all were able to demonstrate that they knew the processes to follow in the event of abuse being suspected. St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 14 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, 20, 21, 22, 24 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There has been little investment to improve the standards for service users resulting in substandard conditions and facilities being provided. EVIDENCE: Service users are accommodated in single bedrooms, some having en-suite facilities. Since the last inspection, some of the bedrooms have been redecorated. It is evident that service users have not been given any choice in relation to the colour of décor to be provided in their room as all rooms have been redecorated in the same colour and style. St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 15 It is of great concern that there has been a minimum of investment into the general improvement and maintenance of the home. Recently, the home was awarded a grant which is to be used to redecorate and refurbish the home. It is evident that service users are not provided with acceptable standards of decoration and furnishings and that no attempt has been made to ensure that the environment has been maintained at minimum standards. A full inspection of the premises was undertaken with the exception of bedrooms that were occupied by service users who were bedfast. Foyer - The carpet in this area is damaged and presents as a tripping hazard. Room 54 - The carpet is stained and worn and requires replacement. The bed rails in this room are not suitable and require to be risk assessed and replaced. Room 53 - The carpet is stained and worn and requires replacement. The bed base is damaged and requires replacement. The water from the tap at the washbasin was excessively hot and presents as a scalding risk. It is necessary that thermostatic mixer valves be fitted to all immersion facilities to prevent the risk of service users becoming scalded. Bathroom by foyer - The tiles around the bath are loose and require attention. The frame over the toilet is unstable and presents as a risk. The décor is poor and requires attention. The seal around the bath requires to be replaced. Sluice - This room smelled offensive. The extractor fan was not working and requires repair or replacement. Room 33 - Requires redecoration. A grab rail is required in the en-suite. Room 35 - Requires redecoration. Ground floor corridor - The carpet is stained and worn and requires replacement. Fire exit - A wire was found to be hanging across the exterior of the door at head height and requires re-fixing. The outside of the fire exit was littered with leaves and debris and requires to be cleared. Rooms 40, 41, 42 and 44 - The carpets are stained and worn and require replacing. Room 43 - The armchair is worn, stained and damaged and requires replacement. St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 16 Room 48 - The flooring is damaged and requires attention. The armchair is worn and stained and requires replacement. Room 3 - The carpet is worn and damaged and requires replacement. The ceiling is stained and requires repainting. Room 4 - The carpet is worn and damaged and requires replacement. The bed base and mattress are stained and damaged and require replacement. Bathroom by room 4 - The bath seat requires to be thoroughly cleaned. The flooring is lifting and presents as a tripping hazard. Room 6 - The carpet is worn and damaged and requires replacement. The carpet trim at the door is lifting and presents as a tripping hazard. Room 7 - The carpet is worn and damaged and requires replacement. The bedside cabinet is damaged and requires replacement. Room 8 - The carpet is worn and damaged and requires replacement. Room 9 - The carpet is worn and damaged and requires replacement. The armchair is worn and stained and requires replacement. Room 1 - The carpet is worn and damaged and requires replacement. The bedrails in this room are not suitable and require to be risk assessed and replaced. Room 23 - The bedside cabinet is damaged and requires replacement. The vanity unit is damaged. The bed rails in this room are not suitable and require to be risk assessed and replaced. Bathroom 14 - The ceiling is damaged and stained. The extractor fan was not working. Room 12 - The carpet is worn and damaged and requires replacement. The vanity unit is damaged. Rooms 13 and 58 - The carpets are worn and damaged and require replacement. Room 19 - The bedside cabinet is damaged. Bathroom 56 - The water from the tap was excessively hot and presents as a scalding risk. The bath seat requires to be thoroughly cleaned. Second floor corridor - The carpet is lifting and presents as a tripping hazard. St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 17 Room 57 - The bedside cabinet is damaged and requires replacement. Room 58 - The wardrobe in this room was extremely unstable resulting in the wardrobe tipping over if both doors are opened. This wardrobe requires to be affixed to the wall. Room 59 - The chest of drawers is damaged and requires replacement. There is evidence of water damage to the wall by the ceiling which requires redecoration. Rear stairwell - The wall is damaged and requires repair and redecoration. Main lounge - There is water damage to the ceiling and the wallpaper is coming away from the wall. Wall by room 62 - A circuit board with breakers is mounted on the wall and there is evidence of damp around it which may present as a risk. It is clearly evident that the owners have failed to maintain the property or the facilities to an acceptable level. The manager explained that the grant money will be used to rectify all the above defects, however, at present, service users are not provided with basic facilities at present and are not accommodated in a homely or well maintained environment. The hairdressing room on the lower ground floor has limited access. A full risk assessment is to be made on the use of this room particularly in the event of fire where service users are unable to use the stairways to evacuate the area. Money has also been left to the home to improve the garden area. The gardens are accessible to wheelchair users but are in a poor condition. Bars of soap were seen in communal toilets and bathrooms. The home is strongly advised to use liquid soap to avoid the risk of cross infection. Service users are placed at risk due to the failure to maintain and upgrade the home to a satisfactory level. St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a lack of evidence of staff training to ensure that the needs of the service users can be met. EVIDENCE: Rotas indicate that there are sufficient trained nurses, senior care staff and health care workers on duty throughout the day and night although the rota does show that a number of staff work excessive hours. There are separate domestic and kitchen staff and the home employs a handyman and an administrator. The home has a detailed recruitment policy and procedure to follow. All files inspected were found to contain a completed application form and interview assessment form. Criminal Record Bureau and Protection of Vulnerable Adult checks are made and a record of these is held. Two references are taken for all staff but some were provided by friends rather than previous employers. Copies of birth certificates, proof of identification and passports are held. Home Office work permits were in place for overseas staff. Records were not seen of regular supervision or annual appraisals. There was no evidence to show that all staff had completed mandatory training. St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 19 A pre-inspection questionnaire was sent to the home for completion prior to the inspection. The question requesting information regarding the number of staff who have achieved NVQ qualifications was not completed. The ability of one nurse was questioned as a photograph of a wound described it as being of the right elbow, left foot and left shin. The documentation showed that this was recorded on two occasions by the nurse. The manager was requested to investigate this, take appropriate action and to inform CSCI of the outcome of his findings. All new staff are required to complete an induction training programme. The documentation to provide evidence of this training is comprehensive but only allows a period of one week for it to be completed. There is little diversity in the staff team and its composition does not reflect the culture of people using the service, particularly at night. St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst the management of care is good, the poor management of the premises has deprived the service users with a safe and pleasant environment in which to live. 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. St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 21 The registered provider visits the home each month but it is of concern that the high number of issues raised in this report as requiring attention have not been noted or have been noted but not addressed to the detriment of persons living at the home. There is evidence that the care given to service users is good but the environment compromises the high standard that the nurses and care staff strive to achieve. No evidence was seen of any quality assurance audits on the home to obtain the views of the service users, their relatives or the staff team. Safety records and certification was in place and up to date. It is recommended that regular tests are made for Legionnaires bacteria. St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 2 3 2 X 2 X 1 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 2 X 1 St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 23 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 OP19 Regulation 23 Requirement The registered person must ensure that the worn and dirty carpet fitted to the ground floor corridor is replaced. Requirement for this to be met by 31/01/07 has not been met. The registered person must ensure that the damaged tiles in the kitchen are repaired or replaced. The registered person must ensure that appropriate equipment is provided to ensure that food is stored at and cooked to an appropriate temperature. The registered person must ensure that all staff are given training in the protection of vulnerable adults. The registered person must ensure that all damaged, worn and stained carpets are cleaned or replaced as appropriate. Timescale for action 31/12/07 2. OP15 23 12/10/07 3. OP15 16(2) 12/10/07 4. OP18 OP28 13(6) 31/12/07 5. OP19 16 31/12/07 St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 24 6 OP19 13(4) The registered person must ensure that all tripping risks are identified and removed. The registered person must ensure that risk assessments are prepared in relation to bed rails and appropriate bed rails fitted. The registered person must ensure that all damaged furniture is replaced. 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. The registered person must ensure that adequate ventilation is provided in all bathrooms and WC’s. The registered person must ensure that all fire exits are cleared. 12/10/07 7. OP19 13(4) 12/10/07 8. OP24 16(2) 31/12/07 9. OP19 13(4) 12/10/07 10. OP19 23(2) 12/10/07 11. OP19 23(4) 12/10/07 12. OP19 OP24 23(2) The registered person must 31/12/07 ensure that all areas of the home are reasonably decorated. The registered person must ensure that a fire risk assessment is undertaken on the hairdressing room to ensure the safe evacuation of service users in the event of fire. 12/10/07 13. OP19 23(4) 14. OP26 23(2) The registered person must 12/10/07 ensure that all areas of the home are maintained in a clean condition. The registered person must ensure that staff are given training appropriate to the work DS0000025418.V343523.R01.S.doc 15. OP30 18(1) 31/12/07 St Michael`s Manor Version 5.2 Page 25 they are to perform. 16. OP36 18(2) The registered person must ensure that staff are appropriately supervised. The registered person must ensure that the registered person or their representative completes written reports following monthly inspection visits. The registered person must ensure that effective quality monitoring systems are in place. 31/12/07 17. OP33 26 12/10/07 18. OP33 24 31/12/07 19. OP38 12, 13, 16 The registered person must & 23. ensure that the health, welfare and safety of service users and staff is protected. 31/12/07 St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 26 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. 4. 5. 6. 7. Refer to Standard OP19 OP19 OP19 OP7 OP20 OP22 OP27 Good Practice Recommendations Thermostatic mixer valves should be fitted to all hot water outlets to avoid the risk of scalding. Unstable wardrobes to be affixed to the wall. That liquid soap is provided at all washbasins in communal areas. The use of correction fluid is discontinued. That the gardens are made available to service users. That grab rails are fitted in all en-suite facilities. That sufficient staff are employed to prevent staff from working an excessive number of hours. St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo L22 0LG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Michael`s Manor DS0000025418.V343523.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!