Care Home: St George`s (Wigan) Limited

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What the care home does well St Georges is a well - managed and well run home ensuring a good standard of care for the people living there. The home offers good support to relatives of people living at the home. Relatives are welcome to join the Friends of St Georges group, that meet on aregular basis for social events and to discuss and plan future events within the home. The premises were clean, and safe and the standard of accommodation is continuing to improve. There have been few staff changes, so residents are looked after by people they know and can trust. Records are kept to a good standard, the office is well organised and everything is to hand. There are additional checks and audits in place to ensure everything is accounted for. The service is not complacent and looks to continually improve. Relatives are made welcome and involved in the running of the home where possible. What has improved since the last inspection? The opening of the newly refurbished dementia unit has greatly improved the environment for the residents living there. The unit is brighter and airy and the rooms have been tastefully decorated and furnished. An enclosed patio leading directly from the dementia unit had been built, providing a safe area for sitting and recreational purposes. The staffing structure has been changed in response to identified shortfalls on the evening. The manager has purchased a range of chairs for the lounges and some bedrooms. An electronic intercom system had been installed to allow staff to see who is entering the building. A smoke room has been built on the first floor for residents to use. There had been an improvement to the garden area. New benched seating and a large raised planting box are near the entrance of the home for residents, visitors and staff to enjoy. Floodlights had been installed to the back of the building. CARE HOMES FOR OLDER PEOPLE St George`s (Wigan) Limited Windsor Street Wigan Lancashire WN1 3DG Lead Inspector Judith Stanley Unannounced Inspection 11th June 2008 09:15 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 George`s (Wigan) Limited DS0000055720.V365985.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 George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St George`s (Wigan) Limited Address Windsor Street Wigan Lancashire WN1 3DG 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) 01942 821399 pauline@sgnh.f2s.com St George`s (Wigan) Limited Patricia Blackett Care Home 62 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (12), Old age, not falling within any other of places category (38), Physical disability (6), Terminally ill (6) St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered for a maximum of 62 service users to include:up to 38 service users in the category of OP (Older People) up to 12 service users in the category of DE(E) (Adults with Dementia over 65 years) up to 2 service users in the category of DE (Adults with Dementia under 65 years) up to 6 service users in the category of PD (Physical Disability under 65 years) up to 6 service users in the category of TI (Adults with Terminal Illness) The service should employ a suitable qualified and experienced manager who is registered with the Commission for Social Care Inspection. Two named service users in the category of DE (Adults with Dementia under 65 years) may be accommodated within the overall number of registered places Sufficient staff must be on duty at all times who are trained and competent to meet the needs of service users, taking account of changing dependency levels and special needs. 19th July 2007 2. 3. 4. Date of last inspection Brief Description of the Service: St. Georges offers nursing and personal care and support for up to 62 residents. A small dementia care unit offers care and accommodation for residents with dementia related illnesses. St Georges was an old school and is a listed building in the Scholes area of Wigan. Resident’s accommodation is available over three floors, including single and shared rooms. Bathrooms and toilets are available on all floors and in close proximity to bedrooms and the lounge area. Lounges are available on all floors. The main dining room is on the lower ground floor; a second smaller dining area is available on the first floor. There is a large garden at the back of the home with patio area and seating for residents to sit outside. There is also access from the dementia unit to safe enclosed patio area with appropriate seating. The home is situated within walking distance of Wigan town centre and is close to local shops and other facilities, including a large superstore. Public transport St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 5 is easily accessible. The home has a private car park and parking is available on the road outside the home. The current scale of fees at St Georges ranges from £313:77 to £515:00. Additional charges are made for hairdressing and chiropody, newspapers and toiletries. St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection which included a site visit that the home did not know was going to take place was carried out over a 6½ hours on one day. The manager was available to assist with the inspection throughout the day. Part of the time was spent in the office looking at some of the records kept to ensure the home is being properly run. These included some resident’s records (care plans), staff recruitment and training files, menus, activities, medication, accident reports and maintenance and servicing of equipment certificates. The rest of time the inspector spoke with residents and staff. There were no visitors available to speak with during the inspection. Prior to the inspection the manager was sent an Annual Quality Assurance Assessment (AQAA) to complete. This information tells the inspector what the home does well at, how they meet the National Minimum Standards (NMS) and in which areas the home can improve and develop. To find out more about the home comment cards were sent to residents, relatives and staff. Nine staff returned comment cards, one said, “The service does well as we have trained staff on 24 hours. Most carers have an NVQ in care. The nurses meet daily with the manager and feedback any information to staff. We have an ‘open door’ policy, families do not need an appointment to see the nurses or the manager”. Another said, “We are informed of each new resident and his or her care needs. Our service looks after the residents well and staff do their best to help in every way to make the residents comfortable and happy”. Six relatives returned comment cards all were positive with their responses. One said, “The girls are very caring. All our family are very happy with the care our mother receives”. Seven residents returned comment cards and complements were made about the quality of the food, and the support and care given by staff. What the service does well: St Georges is a well - managed and well run home ensuring a good standard of care for the people living there. The home offers good support to relatives of people living at the home. Relatives are welcome to join the Friends of St Georges group, that meet on a St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 7 regular basis for social events and to discuss and plan future events within the home. The premises were clean, and safe and the standard of accommodation is continuing to improve. There have been few staff changes, so residents are looked after by people they know and can trust. Records are kept to a good standard, the office is well organised and everything is to hand. There are additional checks and audits in place to ensure everything is accounted for. The service is not complacent and looks to continually improve. Relatives are made welcome and involved in the running of the home where possible. What has improved since the last inspection? The opening of the newly refurbished dementia unit has greatly improved the environment for the residents living there. The unit is brighter and airy and the rooms have been tastefully decorated and furnished. An enclosed patio leading directly from the dementia unit had been built, providing a safe area for sitting and recreational purposes. The staffing structure has been changed in response to identified shortfalls on the evening. The manager has purchased a range of chairs for the lounges and some bedrooms. An electronic intercom system had been installed to allow staff to see who is entering the building. A smoke room has been built on the first floor for residents to use. There had been an improvement to the garden area. New benched seating and a large raised planting box are near the entrance of the home for residents, visitors and staff to enjoy. Floodlights had been installed to the back of the building. St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 8 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 George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 9 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 George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 10 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): 1,2,3 and 4 were assessed. Standard 6 does not apply as St Georges does not offer intermediate care services. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents and their supporters with up to date information about the home that helps them in making a decision about moving in to the home and the services provided. EVIDENCE: The home has a statement of purpose and a service users guide. This information is available to prospective residents and to residents all ready living at the home. There is different information depending on the care the residents needs for example nursing and dementia or residential care. The information is clear and informs people of what they can expect if they chose to live at St Georges. There is a brochure for residents with mental health St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 11 problems, which is printed in a format that is easy to understand and has pictorial information about the home. The last CSCI report is available in the reception area for anyone to read if they want to. Five residents care plans were chosen for inspection. We continued to use the same five care plans throughout the inspection. We asked to see the contract/terms and conditions for those five residents. These were kept in the administrator’s office separate from the main care plan. All five residents had been issued with a contract regardless of whether they paid for their own care or were funded by social services. All five care plans were found to contain a pre admission assessment. This is carried out prior to a resident entering the home. The assessment is carried out by the manager or one of the nursing team at the most convenient place for the prospective resident to ensure that the home and staff can meet the individual care needs of the resident. The assessment covers all the residents details such as name, address, date of birth, next of kin, known allergies, medical conditions, past occupation, hobbies and interests. Further information covers the residents doctor, current medical concerns and what medication is required, what other service the resident had been receiving such as dentist, chiropody, optician and if any hospital appointments had been made. Areas of risk are looked at for example history of falls, smoking, moving and handling etc. The assessment covers any special equipment needed, hospital bed, pressure-relieving cushion or mattress, walking aids, wheelchair, bed rails and bed rail covers and use of the hoist. Activities of daily living are assessed and these cover personal care, washing, dressing, bathing oral and foot care, condition of skin, diet, communication, hearing, sight and if two carers are needed to assist with these tasks. For residents with dementia, the manager also carries out a mini mental state examination (MMSE) to determine the resident’s mental state and cognition and prepares the mild, moderate, or severe dementia plan the home has formulated. The George Formby unit is the dementia unit on the lower ground floor. The unit had been fully refurbished twelve months ago. It offers a lounge/dining area, bathrooms and toilets with suitable aids and adaptations and large, bright bedrooms. Staff had undertaken training in dementia care to ensure that the resident’s needs are met and that staff had an understanding of the different types of dementia and how they present. St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 12 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 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are clear and concise and provide staff with the information they need to meet the needs of the residents. Personal care is offered in such a way as to promote and protect resident’s privacy and dignity. EVIDENCE: Continuing with the same care plans. The information taken from the pre admission assessment provides staff with the immediate information they need to offer the care required. The assessment forms the base line for the rest of the care plan. The care plans are divided in to twelve sections which includes; breathing normally, eating and drinking, elimination, to move and maintain posture, sleeping, ability to select clothing, personal care, avoiding danger, communication, to work at something, to play and participate and to learn. Other information includes, risk assessments, risk managements, and specific St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 13 dementia care plans that promote the health, welfare and safety of the residents. Daily meetings take place between the manager and the nurses to discuss the resident’s health and any changes needed to the care plan. Daily progress notes are recorded at least twice a day. There was evidence to show that outside agencies are such as the district nurse, the doctor, Speech and Language Team (SALT), physiotherapists, diabetic liaison, Parkinson’s nurse and McMillian nurses and the hospice are contacted as required. The manager has formulated a wound strategy whereby if a resident has a pressure sore it will be assessed and if needed the tissue viability nurse is contacted for advice. There is also a falls policy in place, if any resident has three or more falls in a month they are referred to the falls clinic at Whelley hospital. Observation throughout the inspection showed that the personal care needs of the residents were being met. Residents were seen to be clean, well groomed and were nicely dressed. Some residents who were being nursed in bed were in clean nightwear and had had their hair combed. Their beds were clean and had been appropriately made, residents looked warm and comfortable. Staff were kind and tentative to the needs of the residents. The inspector heard staff speaking with residents in a respectful and friendly manner, it was apparent that good relationships had been formed between the residents and staff. To maintain residents dignity and privacy staff were seen knocking on resident’s doors before entering. The manager has instructed all staff that they must ensure that in shared rooms that a person’s dignity is maintained. Privacy screening/curtains are available in shared rooms. The medication for the five residents whose care plans we were working with was looked at. In the main the medication had been given correctly and recorded on the individuals drug sheet. There was one oversight where a tablet had been given but not signed for. This was immediately rectified. Currently there is no one in the home who looks after their own medication, however a policy is in place should this changed and lockable cabinets would be provided for safe storage. St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 14 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 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a wide range of activities to meet their capabilities and expectations. EVIDENCE: The home has an activities organiser and with the help of some residents plans and delivers both indoor and outdoor events. Activities include theme days, such as St Georges Day and St Patrick’s Day celebrations, Easter, Bonfire night and Halloween. Every two months the home has a Tea dance and residents from the sister home in Wallasey are also invited. Other activities include trips out to the local pub, shopping, draughts and cards, bingo, reminiscence, gentle ball games to promote exercise, skittles and foot massage. Residents, relatives and staff were looking forward to the weekend as a summer fayre was planned. St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 15 Activities in the George Formby unit are planned to keep residents active by helping with some domestic tasks such as keeping their rooms tidy, dusting and putting clothes away. Some residents are obviously not well enough to join in activities and staff try to spend quality time with them in their room. Visitors are welcome to visit the home at any time during the day. The only restriction is that visitors are asked to vacate the premises by 20:00 pm to allow the night staff to secure the building and the set the alarms. If this was a problem for a relative, perhaps if someone was poorly, the manager is available to discuss alternative arrangements. Residents are able to meet with their visitors in any of the communal rooms or in the privacy of their own rooms. Consideration should be given to people sharing a room when visitors arrive. The home has regular visits from the Roman Catholic Church. The manager has tried to contact other churches to minister to the needs of other resident’s; unfortunately the local church does not want to visit. Where possible residents are encouraged to make their own decisions about what time they get up and go to bed, what clothes they want to wear, when they would like a bath and what food they want to eat. The inspector observed a member of staff asking people on the George Formby unit what they wanted for lunch and dinner and explaining what choices were available. The menus were available for inspection; these are changed every three or four months and incorporate resident’s likes and choices. A flexible breakfast is served to allow people to get up when they want. A choice of hot and cold breakfast dishes is offered. The main meal of the day is served at lunchtime. On the day of the inspection residents were offered chicken casserole, chipped potatoes and garden peas, or lamb hotpot, followed by fruit sponge and custard. The portions were generous and the meal well presented. Special diets can be catered for as instructed by the manager or nurse in charge. The dining tables were nicely set with matching crockery and appropriate cutlery, condiments, place mats and napkins. Residents spoken with after lunch expressed their satisfaction about the quality and quantity of the food served. A lighter afternoon tea is served; again choices are available including a range of salads and jacket potatoes. St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 16 The inspector observed a resident who was in bed being fed her lunch. It was nice to see the member of staff was sat at the side of the lady talking with her and offering encouragement to eat her meal. Hot and cold drinks are available throughout the day, fresh fruit is in the lounges, and coffee is available for relatives in reception. The home also has a vending machine for snacks and drinks. Suppers are offered before residents retire for the night. St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 17 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 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can have confidence that people will be protected from abuse and have their rights, including the right to complain, protected by effective staff training and procedures. EVIDENCE: A complaints procedure exists and any records of complaints are kept and properly recorded, along with the outcome. The complaints procedure is clearly displayed near the main office. There have been no complaints made to CSCI since the last inspection and none have been brought to the manager’s attention. There have been no safeguarding issues reported by the home within the last year at least. All the nurses had attended courses on the protection of vulnerable adults and all staff has had handouts, watched videos and had covered this topic on induction and on NVQ training. It is the manager’s intention to be able to send all staff on the full day course for the protection of vulnerable adults. St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 18 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, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There had been significant environmental improvements made making St Georges homely, comfortable, clean and pleasant for residents to live in. EVIDENCE: From a tour of the premises, it was evident that the manager had and was still working hard with the staff and the Friends of St Georges to improve the standard of the accommodation and the communal areas. The manager with the help of a relative had painted the lounge/dining area on the George Formby unit. The unit was much brighter and the added lights and fittings make this area comfortable for residents to sit in. The bedrooms on the unit had all been refurbished and were seen to be clean, tidy and comfortable. St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 19 Some residents had personalised their rooms with belongings brought with them from home. It is the manager’s intention that all bedrooms are decorated to the same standard throughout the home. The lounges on both floors were nicely decorated and were well equipped with TVs and music centres. These areas are also used for activities. New lighting on the corridors had been fitted making them brighter and better for residents to move safely around the home. A range of chairs including average and low height and recliners had been purchased for lounges and some bedrooms. A new smoking room has been built on the 1st floor for residents who wish to smoke. The outside of the home was well maintained. Appropriate seating was available and residents benefited from going out more. The enclosed patio leading directly from the George Formby unit enabled residents to sit outside safely. The bird table has proved to be a success especially for one resident who has taken charge of feeding the birds. Systems are in place to control the risk of cross infection and the manager carries out regular checks on bathroom and toilets to ensure cleanliness is maintained. Staff were seen wearing different protective clothing for different tasks. The laundry is sited in the lower ground floor away from food preparation and food storage areas and does not intrude on the residents. The home was clean and free from offensive odours. St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 20 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 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels were satisfactory ensuring consistency of care for people living in the home. Residents were cared for by staff that had been properly and safely recruited. EVIDENCE: On the day of the visit staffing levels were sufficient to meet the needs of the residents. A written rota is maintained. Domestic and catering staff support the care staff. There are two nurses and four care staff on duty throughout the night. Some of the staff had worked at the home for several years and discussion with them showed they knew the residents well. Staff were clear about the work they were employed to do and that they were happy to help each other out. The atmosphere in the home was relaxed and friendly. Interactions between staff and residents were frequent, natural and warm. During the visit staff were observed to respond speedily to requests for assistance made by residents. St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 21 Staff training is progressing well with over 50 of care staff having achieved an NVQ in care. All the kitchen staff had NVQ in cooking and the domestics in housekeeping. All mandatory training and updates are completed as required. All new staff undertakes a full induction programme on commencing work and must be willing to undertake NVQ training as part of their employment. The files of three staff employed were looked at and showed all the necessary recruitment checks had been undertaken. All contained: a written application form, references, POVA 1st check and Criminal Records Bureau (CRB) and verification of identification. St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Georges is well run by a well-qualified, suitably experienced and competent manager. Residents can be sure their best interests will be the central focus, with a positive and inclusive approach to making the service better. EVIDENCE: The home’s manager has a significant number of years experience in working and caring for the elderly. The manager is a registered nurse and has the necessary qualifications to manage a care home. St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 23 The manager is committed to her own training as that of her staff team and sees this an essential element to delivering good quality care for residents. The way in which the home is run is open and transparent. The manager operates an ‘open door’ policy so that she may be approached by staff, residents and their families at any time. The office was well organised and staff have access to all the paperwork and contact information they need during the shift. There are additional systems in place to check that everything is recorded when it should be and kept up to date. The manager has administrative support to assist her as needed. There is a good system of continuous monitoring in the home, which includes satisfaction questionnaires to residents and visitors to the home. The home holds residents/ relatives and staff meetings of which the minutes were available for inspection. There is internal auditing, which includes: toilets and bathrooms, kitchen, cleaning, bedroom checks, medication, hand washing, food satisfaction, laundry, wound care and accidents etc. The owner of the home visits on a regular basis, it is a legal requirement that he or an appointee who is not directly concerned with the conduct of the care home completes monthly written reports. The reports had been signed by the owner but had not always written by him. Some residents have handed over small amounts of money to the home for safe- keeping. The homes administrator oversees this and ensures that records are up to date and any transactions are documented. The money is held in one main account (no interested accrued). All information is stored on computer. Equipment and systems used in the home were serviced and maintained, and records are well kept and easily accessible. On the returned AQAA, the manager provided a record of maintenance and associated records. A sample including the lift, electrics and gas certificates were checked at the site visit and were up to date. Fire safety records showed that all fire tests; fire drills and maintenance procedures had been undertaken. The manager ensures that accidents, injuries and incidents that occur are recorded and the CSCI informed as necessary. St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 4 3 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 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 4 x 3 x x 3 St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 OP33 Good Practice Recommendations The registered provider should complete the monthly report not just sign it off as done. St George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 George`s (Wigan) Limited DS0000055720.V365985.R01.S.doc Version 5.2 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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