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

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 Mount 12/09/07

St Michael`s Mount 21/07/06

St Michael`s Mount 24/01/06

St Michael`s Mount 07/09/04

St Michael`s Mount 07/06/04

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 Mount Woolton Road Woolton Liverpool L25 7UW Lead Inspector John McCabe Unannounced 12 October 2005 09:00 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 Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Michaels Mount 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 Ms.E. Draper. CRH N 45 Category(ies) of OP - 45 registration, with number of places St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) 45 Nursing Care and 45 Personal Care in the overall number of 45 Date of last inspection 7 September 2004 St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 5 Brief Description of the Service: St Michaels Mount is one of two adjacent care homes situated in a quiet residential area of South Liverpool. Both homes are owned by a private company. St Michaels Mount 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 gradens. There is a car park to the side of the home. The building is purpose built and consists of two floors. The upper floor is served by passenger lifts and stairs. Accommodation 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, a separate dining room with conservatory. The home is close to public transport, rail and bus and is near to the M62 and M57 motorways. St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 12/10/05 at 0900 hours with the registered manager of the home. The inspection took place over four hours. 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. A number of residents, staff and a community nurse were spoken to during the inspection period, to get their views on the conduct of the home. The home was not as 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 home has comprehensive documentation, to ensure the safety of the residents, however in one of the residents’ files there was no pre-admission nursing assessment for the resident. Three members of staff currently working the home have no up to date enhanced Criminal Record Bureau (CRB) certificate. The registered manager needs to ensure that the necessary recruitment checks are complete and St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 7 evidence to confirm this is maintained for inspection purposes. The registered manager must also ensure they are aware information regarding CRB and POVA protocols before employing staff in the home. The conservatory roof should be repaired so as to prevent flooding of the conservatory. When residents participate in organised social activities, it should be recorded on the daily health record sheet how they participated in the activity. The paving area in the rear gardens need to be cleaned and all weeds removed from in between the slabs so that they do not present a risk of falls to residents. The home has overseas nurses who are employed as carers; some are waiting to commence an adaptation course for UK Registered Nurses status. It is very difficult to undertake an audit trail on documentation how they gained entry into the UK. Also, it is difficult to evidence what clinical competencies the overseas nurses have achieved in the home before the registered manager of the other home (St Michael’s Manor) authorises in writing, their RN (1st Level Nurse) status to the Nursing Midwifery Council (NMC). The home must display the CSCI certificates at all times in the home. Failure to do so is an offence. 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 Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5. The Home’s Statement of 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. The residents’ pre-admission assessment documentation is robust and comprehensive; and must be completed before residents are admitted to the home to ensure that the skill mix of the workforce in the home can meet the residents identified care needs. EVIDENCE: The Home’s Statement of 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. The home must display the CSCI certificate in a prominent place in the home, at all times, so members of the public are aware of the home’s registration St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 10 details, especially in respect of what category of resident is allowed to be admitted to the home. In one of the residents’ files the pre-admission nursing assessment document was not completed before the resident was admitted to the home. 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 preadmission nursing document is the basis of the initial care plan for the resident and must be completed. Other health care professionals known to the resident should be involved in the pre admission assessment were appropriate. Care staff in the home do undertake specialist care training, which is ongoing, to ensure that the assessed and changing care needs of the residents are met. St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,. 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. 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. Residents and family also contribute the formulation of the plan. Daily health records are documented daily for each resident, this includes any critical incidences plus any visits from GPs, specialist nurses etc. No resident in the home self medicates and all medications for residents are administered by the nurses 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). All residents in the home can access their NHS entitlements, which includes dentistry, opticians and chiropody services. St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 12 Currently there are two residents with pressure area care needs. The nurses in the home address these needs and seek advise of the community Tissues Viability Nurses when necessary. Both residents were admitted from the Primary Care Trust Hospital with the pressure areas. Resident’s documentation is kept secure in accordance with the Data Protection Act 1998. St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15. Residents have choice and flexibility how they spend their day in the home, and can pursue leisure and educational activities according to their choice and preferences. This allows independence and individuality for each resident. 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 a Social Assessment 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. The home does not employ an activities coordinator, carers undertake to organise the social activities. 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. The recordings of St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 14 the resident activities helps to complete a “full picture” of the residents progress, or even identify developing care needs. Visitors are allowed in the home at any reasonable time of 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. None of the residents knew what was for lunch, as no menus cards are printed or a daily menu displayed in the dining room. Therapeutic diets can be catered for in the home for residents with a medical condition. St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 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 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, however one complaint was reported to the commission via the Adult Protection Officer in the Primary Care Hospital (PCT). The complaint, after investigation was not upheld. The home has robust complaints procedures, that are set out in the residents guide and the staff handbook. It was positive to note that residents legal rights to exercise the right vote is encouraged and supported with many of the residents using their postal vote in the last General Election. 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 and there was evidence that many of the staff had undertaken training on POVA protocols, and the Whistle Blowing Policy. St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.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 cleaning of the interior of the home, especially the bathrooms, toilets, conservatory, and the rear gardens, to ensure a safe comfortable environment for the residents. EVIDENCE: The home was not clean and tidy as there was only one domestic on duty. This is a large home with single bedrooms and a number of corridors many of which had not been vacuumed on the day. The task for one person to keep the environment clean is a sizable one. The registered person needs to consider having more domestic staff available to keep the home clean and tidy. Communal bathrooms have been painted, and other bathrooms need partial refurbishment, with attention paid to the grouting in between wall tiles. Since the last inspection the rear gardens have deteriorated. The inspector observed both uneven paving stones and weeds between dirty paving slabs, all St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 17 of which gives the garden area a “look of neglect”. Consequently the area is unsafe for residents to walk alone in the space. Residents, visitors and staff cannot currently use the home’s conservatory as the roof is leaking and causing flooding of the floor area. This means residents are restricted to the lounge area. The roof needs to fixed as soon as possible so residents can have access to the room. All of the bedrooms in the home are single occupancy, and most of the residents have personalised their bedrooms with pictures and memorabilia. 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, and Hepatitis B and C. The homes updated infection control policy includes the prevention and spread of Methicillin Resistant Staphylococcus Aureus and Hepatitis B and C. St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.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 has deteriorated with the appropriate 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 raises concerns that the home does not 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. EVIDENCE: There is always a first level nurse on duty who is assisted by care staff and ancillary staff. A number of 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 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. St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 19 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 have been recruiting overseas nurses form the African and Asian continent. The nurses are recruited to undertake an Adaptation Course/Supervised Practice Course 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 nurses 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 needs. (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. e) The overseas nurse has the required country of origin passport; entry visa and work permit from the Uk authorities. St Michaels Mount 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. During case tracking of the O/N documents it was impossible to evidence, Work Permits, Visas or a confirmation letter from the NMC regards their Uk training. St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 20 It became evident that the O/N were being employed as carers in St Michaels Mount, and that the registered manager from the another home (St Michaels Manor) was then requesting UK work permits for the O/N as Staff Nurses. During this case tracking it also became evident the manager from St Michaels Mount was not registered with NMC, as regards adaptation nurses and the manager from another home (St Michael Manor) was actually registered with the NMC for both homes! The manager from St Michaels Manor, signs the NMC forms for the students in St Michaels Mount to gain their First Level nurse qualification (RN). This situation must be addressed and clarified. O/N in the Mount did inform 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 also recruited O/N in excess of their permitted quota (2) for the Adaptation course. The manager from the Manor attempted to register more than two students from the Mount 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, the management and administration arrangements for recruitment and development of the O/N has worsened, with the manager of the Mount taking a very passive role in 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. The homes manager is not fully aware of the rules regulations laid down by the NMC and Department of Health (DOH) on the recruitment and training of overseas nurse. This is a serious concern as clearly they have the responsibility to ensure that the staff at the home are fit to work in the home, appropriately supervised and that they receive training appropriate to the work they perform. The rules and regulations for overseas nurses and Adaptation course changed on the 1st September 2005. St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 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 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) 31,32,33,34,35,3637. 38. Staff morale is high in the care home, resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life, plus 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. EVIDENCE: An experienced first level nurse manages the home; currently the manager has not registered on an NVQ Level 4 care programme. St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 22 All staff in the home have documented supervision six times per year, this ensures 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 gives the staff and managers opportunities to discuss their own/or identified training needs. A community nurse told the inspector that every time she came to the home, care staff were always polite and courteous to residents, and the nursing staff always complied with any instructions from the community nurses, as regards care practices for the resident. Where possible residents look after their own financial affairs, 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 Employers Liability Insurance certificate is displayed in the main hall of the home and is valid and in date. St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 2 3 3 3 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 2 3 3 3 3 3 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 3 3 3 St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 24 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 31 Regulation 43 Requirement The Registered person must ensure that the CSCI certificate is displayed in full, at all times in the care home. The registered person must ensure that a pre-admission assessment is undertaken on all residents before they are admitted to the home. The registered person must ensure that when residents participate in organised social activites it is recorded on their daily health record sheet The registered person must ensure that the leaking conservatory roof is repaired, to allow residents use of the room The registered person must ensure that the paving area at rear of the garden is cleaned, and weeds removed to ensure the safety of staff and residents. The registered manager must ensure that there is sufficient domestic staff on duty to keep the home clean and tidy The registered person must ensure that no staff are employed in the home without an up to date enhanced Timescale for action 31/10/05 2. 3 14 31/10/05 3. 12 12 31/10/05 4. 19 23 31/10/05 5. 20 23 31/10/05 6. 26 23 31/10/05 7. 29 19 31/10/05 St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 25 8. 31 9 CRB/POVA certificate, or a POVA fiirst The registered person must ensure that the registered 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. 31/10/05 9. 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 Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI St Michaels Mount F52_F02_S25184_StMichaelsMount_V230558_121005_Stage 41.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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