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What the care home does well What has improved since the last inspection? Records have been improved to include the person`s likes and dislikes rather than just their health care needs. This enables staff to care for the person how they would choose and reflects good practise. A webcam has been purchased to enable people to keep in touch with over seas relatives and friends. This also reflects good practise. Training for staff has developed greatly so that the staff team has more than the expected skills required to meet the needs of the people who live at the home. The people who live at the home requested to meet the families of staff who work there. A garden party was organised so that this could take place. This shows a commitment from staff to ensure that the home is run as a domestic house would be and that trusting relationships have developed between staff and the people who live at the home. A number of improvements have been made to the environment including purchasing new furniture, a new kitchen and redecoration to many parts of the home. The people who live at the home are enjoying more organised day trips out to local places of interest. What the care home could do better: The home could introduce the use of nutritional risk assessment templates to help staff quickly identify who is at risk from the information that staff have already gathered. This could help prevent the risk of information getting lost in other documents. Generally medications are managed safely however staff should keep a record of all medications that are destroyed in the home. This would mean that a clear audit trail would be available for all medications received into the home as well as those administered and destroyed. Written guidance should also be provided identifying when the use of " give when required" medication should be offered. This would potentially reduce the risk of someone being given medication that they don`t need or of staff having to deal with potential challenging behaviour, which could have been avoided through the use of medication. Menus should be reviewed to ensure that the people who live at the home are being offered five portions of fruit and veg per day as per the government guidelines for health eating. Introducing the use of a grumbles book could support the complaints procedure for the people who live at the home. This may encourage more people to raise concerns who may find the thought of making a " formal complaint" intimidating. Portable electrical appliances within the home must be tested to ensure that they are still safe to use by the people who live at the home and the staff who work there. The manager should sign all accident records to show that she has viewed them. CARE HOMES FOR OLDER PEOPLE St Michael`s 93 St Michael`s Church Road Liverpool Merseyside L17 7BD Lead Inspector Mrs Joanne Revie Key Unannounced Inspection 09:30 6th December 2007 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 DS0000025185.V340932.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 DS0000025185.V340932.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Michael`s Address 93 St Michael`s Church Road Liverpool Merseyside L17 7BD 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) 0151 728 9019 Colette.Marks@ageconcernliverpool.org.uk Age Concern Liverpool Colette Elizabeth Marks Care Home 12 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (12) of places St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only: Code PC, to service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia over 65 years of age: Code MD(E). The maximum number of service users who can be accommodated is: 12. Date of last inspection 17th May 2006 Brief Description of the Service: St Michaels is a single storey purpose built care home providing nursing care for 12 older people with functional mental ill health. The home is situated within a residential area of Aigburth South Liverpool. The property is within walking distance to shops, pubs, Sefton Park and a bus ride from Liverpool city centre and other places of local interest. Accommodation at St Michaels includes12 single bedrooms all fitted with wash hand basins. There is a large lounge and dining room. The dining room leads onto a patio area and large walled garden Although the home is registered to provide nursing care for people over the age of 65 with enduring mental health needs. There is a strong emphasis on promoting peoples independence and developing quality lifestyles. Staff are particularly good at empathising so people who live at the home are inclined to feel safe and accepted which helps to reduce deteriorating mental health symptoms. The service employs general nurses as well as mental health nurses, which means that the staff team are able to provide physical as well as psychological support. St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the site visit taking place the manager was asked to complete a document called an AQAA. This is a document, which gives information about the services strengths and weakness, and future plans for the service to develop further. Once the AQAA was received, surveys were sent out to the people who live at the home and the staff who work there. Nine of these were returned completed to CSCI. During the site visit, discussions were held with people who live at the home, visitors and members of the staff team. Their views have been included within the report. The site visit was unannounced and lasted five hours. A variety of records were viewed which refer to the health and welfare and care received by the people who live at the home. This review also included viewing staff records. There is a strong emphasis on the people who live at the home being treated as individuals with individual needs and wishes. For this reason Equality and Diversity is managed well and staff have recently received updated training on this subject. The cost of living at the home is £476.00 per week. What the service does well: There are a number of areas that the home has been commended as achieving greater that the national minimum standard required. This reflects god practice and shows willingness by the staff team to develop the service further. People who are interested in moving into the home are given as many opportunities as they need including visits to the home to help them decide whether the home is the right place for them to live. The information gathered during these visits is formulated into a plan so that staff have written instructions telling them how to care and support the person in the way that they need and how they would like. The variety of skills available in the staff team means that people’s health care needs (physical and psychological) are met and staff are quick to respond in the right way if changes occur. St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 6 The people who live at the home are consulted on all aspects of their care and daily life including food, how they wish to spend their time etc. People are treated, as individuals with individual needs who require individual support. Staff have developed trusting relationships with the people who live at the home and comments were made by people who live there such as” They’re good- yes I trust them- sometimes I give them a bad time but they never change- They’re always there for you- in fact I’ve never seen any of them getting mad at anyone”. Thorough staff recruitment takes place to ensure that the people who live at the home are protected and staff have the skills and knowledge to protect people from abuse. One person said – I trust them to do the right thingthey’re good people” The staff team have the skills to support the people who live at the home and extra training has been provided to develop their roles further which reflects very good practice and shows willingness by the organisation to invest in its staff. The home is a warm comfortable clean place to live and the people who live there are encouraged to make their bedrooms their own by personalising them to their tastes. Wherever possible the home is managed in the same way that a domestic home is managed. The manager and staff team have good insight and show great empathy to the people who live at the home. What has improved since the last inspection? Records have been improved to include the person’s likes and dislikes rather than just their health care needs. This enables staff to care for the person how they would choose and reflects good practise. A webcam has been purchased to enable people to keep in touch with over seas relatives and friends. This also reflects good practise. Training for staff has developed greatly so that the staff team has more than the expected skills required to meet the needs of the people who live at the home. The people who live at the home requested to meet the families of staff who work there. A garden party was organised so that this could take place. This shows a commitment from staff to ensure that the home is run as a domestic house would be and that trusting relationships have developed between staff and the people who live at the home. A number of improvements have been made to the environment including purchasing new furniture, a new kitchen and redecoration to many parts of the home. St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 7 The people who live at the home are enjoying more organised day trips out to local places of interest. What they could do better: The home could introduce the use of nutritional risk assessment templates to help staff quickly identify who is at risk from the information that staff have already gathered. This could help prevent the risk of information getting lost in other documents. Generally medications are managed safely however staff should keep a record of all medications that are destroyed in the home. This would mean that a clear audit trail would be available for all medications received into the home as well as those administered and destroyed. Written guidance should also be provided identifying when the use of “ give when required” medication should be offered. This would potentially reduce the risk of someone being given medication that they don’t need or of staff having to deal with potential challenging behaviour, which could have been avoided through the use of medication. Menus should be reviewed to ensure that the people who live at the home are being offered five portions of fruit and veg per day as per the government guidelines for health eating. Introducing the use of a grumbles book could support the complaints procedure for the people who live at the home. This may encourage more people to raise concerns who may find the thought of making a “ formal complaint” intimidating. Portable electrical appliances within the home must be tested to ensure that they are still safe to use by the people who live at the home and the staff who work there. The manager should sign all accident records to show that she has viewed them. St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 8 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 DS0000025185.V340932.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 Michael`s DS0000025185.V340932.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): 3, Standard 6 was not assessed, as the service does not provide intermediate care. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Each person receives a thorough individual assessment. EVIDENCE: Assessments are undertaken on all new people before they move in. How this occurrs is adapated to each individual. Members of the staff team undertake visists to meet the person according to their needs. E.g if the person has dietary problems than a member of the catering team will accompany the manager.This is very good practise.If necessray the staff team will visit the person several times and in return the person can visit the home as often as needed before they make a decision. Copies of completed assessments showed that a very detailed record is made of the persons needs ,likes and dislikes including how they wish to spend their St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 11 time. A comprehensive psycolgocal assessment and physical assessments is carried out . St Michael`s DS0000025185.V340932.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): Quality in this outcome area is good. 7,8,9,10 This judgement has been made using available evidence including a visit to this service. The people who live at the home are supported to maintain their personal care and health needs. EVIDENCE: Four care plans were viewed which contained detailed information about the person’s needs, likes and dislikes. All instructions were clearly explained with detailed explanations of the care required. The owner had signed documents within the plans, which showed their involvement. The plans viewed had been reviewed three monthly rather than monthly. The manager is carrying our audits and identifying any omission in the plans with the nurse is responsible for overseeing its completion. Staff are keeping clear daily records and are referencing their records to each of the persons needs, which shows that they are referring to and reading the plan. This is good practise. Four surveys were received from people who lived in the home that reflected positively on the staff’s ability to care. The six staff surveys received stated St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 13 that they believed that the home offered a high standard of care. The home employs general nurses as well as mental health nurses and some staff hold both qualifications. This is good practise and shows that although the service predominantly provides support for mental health needs, its also recognises that some of the people who live at the home have physical needs also. Each of the plans viewed contained records which showed that staff are quick to take action if a persons health needs change and that other health care professionals regularly visit the people who live in the home. Everyone is weighed on a weekly basis and the manager was able to explain and show records detailing action that had been taken following on a persons recent weight loss. This included encouraging a high calorie diet and supporting the person to have x-rays taken. Some people who live in the home suffer from diabetes. Records showed that this monitored by the nursing team and that the kitchen staff have received training in the management of this illness. Staff have received training, which meets the health needs of the individuals who live in the home. (See staffing section) Each of the plans viewed contained risk assessments, which had been written and developed around the persons indivual needs. This reflects good practise and were evidently working documents that are an important part of the overall plan of care. Risk assessments were also in place regarding the persons physical needs, e.g. risk of developing pressure sores. Although peoples weight is monitored no formal process exists to monitor a persons nutritional status. This was discussed with the manager who intends to explore the introduction of nutritional risk assessments. During the visit staff were observed providing support. This was done in a dignified manner. Some people were supported to stay in their bedrooms. One person was left undisturbed as they were sleeping. All staff knocked on doors before entering and were heard to call the people who live at the home by their first name. The homes medication systems were observed. Generally these are managed safely with staff keeping clear records of all receipt and administration. However staff were not keeping records of any amounts destroyed. This must be addressed so that a clear audit trail is vailbale. Medication audits are carried out which is god practise. Some people who live at the home require “ give when required” medications for lapses in mental health. It would be beneficial if “ trigger points “ were developed. This would mean that staff would have a clear understanding of exactly when to give “ give when required medication”. St Michael`s DS0000025185.V340932.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): 12,13,14,15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people who live at the home are consulted about all aspects of their daily life including how they wish to spend their time and which food they would like to eat. EVIDENCE: The people who live at the home are encouraged to celebrate their birthdays by receiving a cake and a present. 3 staff who are employed as nurses/carers over see the organisation and provision of activities. Rotas have been developed following consultation with the people who live at the home. A choice of activities is provided each day, which reflects good practise. Two white boards are displayed in the home, which clearly details which staff are on duty, day date, weather, forthcoming activities etc. Four care plans were viewed which contained comprehensive checklist of activities that the people are interested in or not. Staff keep records of activities in a dairy. This was viewed which showed a trip out to a forthcoming pantomime at Liverpool St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 15 had been arranged. The plans viewed showed that individual as well as group activities occur inside and outside the home. The home has access to a mini bus, which is used, for trips out to local places of interests. Family and friends are encouraged to visit the home. One person is supported to keep in touch with her family who live overseas via a web cam, which is very good practice. The manager explained that holidays did used to occur but that in recent years this has not been so frequent. However plans have been developed for some of the people who live at the home to spend a long weekend at Blackpool. Staff were observed making visitors welcome when they arrived at the home. Following a request from the people who live at the home, a garden party was organised last year for staff to introduce their families to each other. Minutes were viewed of meetings that showed that the people who live at the home are regularly consulted about how they wish to live their lives and spend their time. Two people are supported to clean their own bedrooms and carry out light domestic chores as would occur in their own homes. Meal times are flexible according to people’s wishes and staff are aware of everyone’s likes and dislikes as recorded in the plans of care. The people who live at the home are also supported to make informed choices regarding their health care needs, which is good practice. Menus were viewed, which showed that a variety of meals are served at the home and that choice is available according to what people, feel like eating. Takeaway meals regularly occur as would happen in a domestic home. The chef keeps a record of any changes that occur to the menu so a record is available showing what people have chosen to eat every day. Snacks abd drinks are available through out the day. Menus were also viewed which showed that the kitchen staff have a good understanding of specialist diets such as weight reducing. The chef was in the process of reviewing the menus, which occurs regularly to promote choice. During this review it would be beneficial if the meals were reviewed to see if the people are offered five portions of fruit and veg a day as `recommended Healthy eating government guidelines. St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 16 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People know how to complain and trust staff to act on their concerns. EVIDENCE: The home has a robust complaints procedure, which is clearly displayed, and people are aware of. No complaints have been made to CSCI of the home since the last inspection. A discussions with the manager revealed that the people who live at the home view the complaints procedure as a formal process, which may prevent them from using it. The introduction of a less formal system such as a “ grumbles book” could help alleviate this and support the formal procedure, which is in place. People who live at the home said that they trust the staff. Staff training records showed that staff have had training on how to protect vulnerbale adults from abuse and a copy of the local councils procedures were available. All incidents within the home are correctly recorded and acted on. St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 17 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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is a clean, warm comfortable place to live EVIDENCE: The building was viewed. All areas appeared clean, tidy warm and well decorated with good quality furnishing. The service has purchased new dining room furniture since the last visit to enable people to have more choice of who they sit with. Each person has their own bedroom and these were decorated with different schemes and contained personal effects so that the impression was given that people had made these rooms their own. St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 18 The home is hoping that a conservatory can be provided for the people who live at the home who smoke, as currently they have to smoke outside. The staff at the home have the skills and knowledge to deal with infection such as MRSA. Supplies of disposable aprons and gloves and alcohol hand rub to reduce spread of infection are readily available. The home has a domestic style kitchen, which was clean and organised in line with current good practice and a separate laundry room, which is well equipped with industrial style machines. The manager has received the NHS guidelines” safe steps to cleaner care” and intends to review and where necessary implement any changes. Domestic staff are employed on a daily basis, which helps to ensure that the home is clean tidy and smelling fresh. St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The staff teams skills are diverse and staff are provided in sufficient flexible numbers to able to support the people who live at the home. EVIDENCE: The home employs registered general nurses as well as mental health nurse as it has recognised that some of the people who live at the home require support with physical needs. This is very good practise. The home has a minimum staffing level of one qualified nurse and two carers plus the cook and a domestic during the day and over night one qualified nurse and two carers who are all waking staff members. The off duty showed that staffing levels fluctuate according to what is happening in the home on a daily basis but never drop below these minimum level’s. This reflects very good practise. The staff at the home are given the opportunity to train for NVQ qualifications through Age concerns training department. The manager is qualified to support then through this process. Eight of the ten permanent staff employed have achieved an NVQ qualification in care. Viewing staff personal files showed that the manager ensures that necessary checks are carried out on all new employees to ensure that they are suitable to St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 20 work with vulnerable adults. New staff receive a thorough induction and support (depending on their experience) to carry out their role. The manager sources training from Age concern and also outside independent trainers. Staff have praised the content and amount of training offered. Staff have covered topics that would be expected to enable them to meet the needs of the people who live in the home but have also undertaken training in other areas such as ageing and dying equality and diversity, forthcoming changes in the mental health act, diabetes, understanding dementia etc. This reflects very good practise and shows a willingness to develop the staff team St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in the best interests of the people who live there. EVIDENCE: The manager is registered with CSCI and has the skills and experience to manager the home. The manager showed great insight and understanding to the needs of the people who live at the home. The manager is in the process of completing a registered managers award qualification. The manager was previously employed at the deputy manager for the service. Records were viewed during the visit which showed that the manager monitors staff performance and provides support and guidance when lapses occur. Staff spoke positively of her ability to manage. St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 22 The people who live at the home are consulted in a number of ways about what they think of living at the home. This is good practise but could be developed further by collating the information into an annual report which could summarise all the views expressed. Robust systems exist to ensure that people are supported to manage their money safely. This includes ensuring money can be accessed at any time for those people who want it. A variety of contracts and certificates were viewed which relate to Health and safety. These were presented in a very organised format, which had been compiled, by the Health and Safety officer. This person is a staff member who has had her role extended and developed to undertake this role. Training has been given to enable her to execute her duties well. This is very good practise .All aspects of health and safety were found to be current and regularly reviewed with the exception of the portable appliance testing. This has not occurred for over a year due to staff absence. This must be addressed to ensure that the health and safety of the people who live at the home and the staff who work there is maintained. Staff keep clear records of any accidents that occur within the home. Although the manager reviews these records she does not sign to show that this process has occurred. St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X X 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 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 24 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. 1 Standard OP38 Regulation 13.2 Requirement Timescale for action The portable electrical appliances 01/03/08 must be tested to ensure that they are safe to use by the people who live at the home and the staff who work there. 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 OP8 Good Practice Recommendations Consideration should be given to introducing the use of nutritional risk assessments as a way of recording a person’s nutritional status. Records of all medications destroyed should be kept within the home so that a clear audit trail exists Written trigger points should be developed so staff know exactly when to administer PRN medication. 2 3 OP9 OP9 St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 25 4 OP15 Menus should be reviewed to ensure that the people who live at the home are being offered five portions of fruit and veg per day. The manager should consider introducing a “ grumbles” book to support the formal complaints procedure. The manager should “ sign” to show that she has reviewed accident records. 5 6 OP16 OP38 St Michael`s DS0000025185.V340932.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Michael`s DS0000025185.V340932.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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