Inspection on 17/05/06 for Craghall Residential Home

This inspection was carried out on 17th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Craghall Residential Home 03/05/07

Craghall Residential Home 16/01/06

Craghall Residential Home 27/07/05

Craghall Residential Home 06/01/05

Craghall Residential Home 24/06/04

Craghall Residential Home 24/02/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Craghall Residential Home Matthew Bank Newcastle Upon Tyne Tyne & Wear NE2 3RD Lead Inspector Elaine Malloy Key Unannounced Inspection 10:00 17th & 18th May 2006 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 Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 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. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Craghall Residential Home Address Matthew Bank Newcastle Upon Tyne Tyne & Wear NE2 3RD 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) 0191 284 6077 Wellburn Care Homes Limited Mrs Christine Barbrook Care Home 38 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (32) of places Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: Craghall is a care home that provides personal care to 32 older people and 6 older people with dementia. The home is located in South Gosforth and has extensive well-kept grounds and car parking space. The property was converted to a care home. A major refurbishment and extension was completed in November 2004. This included installation of a passenger lift, stair lift and ramped areas to aid access. There are 34 single and 2 double bedrooms, 30 of which have en-suite facilities. Four bathrooms and a shower room are provided. There is access by public transport. Local amenities and shops are available in Gosforth and Jesmond. The current weekly fees range from £375 to £428. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection. It was carried out by one inspector over 2 days and took 10½ hours. Key standards were inspected through discussion with the manager, staff and residents, examining the home’s records and touring the building. Surveys were made available to residents and their relatives/visitors to get feedback on the service. Each of the areas that needed improvement from the previous inspection was checked. What the service does well: Residents spoke highly of life in the home and said they were well looked after. New residents care needs are assessed before moving into the home. Residents confirmed their privacy and dignity is respected. There is varied programme of social activities and outings. Residents are supported to maintain contact with family, friends and the local community. Residents are encouraged to make choices and decisions in daily living. A good menu is provided and residents are consulted about the food. Residents understand how to make complaints. The building and grounds are maintained to a high standard. Good staffing levels are provided to meet residents needs. Staff have opportunities for training, including courses that lead to achieving care qualifications. The home has an experienced manager who is studying to gain a management qualification. Resident finances are suitably safeguarded. There are good systems in place to comply with health and safety requirements. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable, as the home does not provide intermediate Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents’ needs are assessed before they move into the home. EVIDENCE: New residents care records showed evidence of assessment of care needs before admission. Care Managers had also provided the home with their assessments where care is funded by Social Services. The inspector talked to residents who had recently moved into the home. They were generally positive about staff understanding their care needs. However one lady said at times she had to ask staff to provide some minimal assistance with dressing in the mornings. She also said she wanted equipment to aid independent toileting from her own home. These comments were relayed to the manager. She agreed to make sure all staff were made aware of assistance needed, and arrange to collect the equipment. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Resident care needs were not always properly identified and set out in care plans. Arrangements are in place to access health care professionals and meet health needs. Continence management requires improvement. Medication recording is still not to an acceptable standard. Care practices promote residents rights to privacy and dignity. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 10 EVIDENCE: A sample of care records was inspected. A range of assessment tools is completed. These cover physical and mental health, personal care, social needs, moving and handling, risks including risk of falling, and nutrition. There is a system in place for checking that assessments are updated, care plans are evaluated, and individual care reviews are conducted. The resident files examined lacked evidence of clear links between their assessed or identified needs and care plans. Example of this were: • • • • • A new resident’s care plans that were incomplete. No care plans for risk of falls, and incontinence, despite these needs being evident from the resident’s daily reports. No care plan for a resident that showed how a physical problem could trigger agitated or aggressive behaviours (This was introduced the following day). Plans for managing continence difficulties were not specific and toileting programmes were not being used. The daily reports on individual residents were often bland and did not give any qualitative information. The recording system to cross-reference entries to numbered care plans was not used. The inspector and manager discussed standards of care records and the introduction of audits to monitor quality. Residents care records demonstrated evidence of input from health care professionals. Five GP practices are used. Mental health professionals are accessed as needed. One lady currently has visits from a Community Psychiatric Nurse. The District Nurse was visiting twice weekly, and as required. Arrangements are in place for visits from NHS and private podiatrists, optician, and dentist. As previously stated, assessment and promotion of continence needs development. Two residents continue to administer their own medication. Risk assessment was carried out and lockable storage facilities are provided. Senior staff who have completed ‘safe handling of medicines’ training administers medication four times daily. Medication records were examined. There are photographs of the residents on records for identification purposes. At the previous inspection there was an outstanding Requirement that there must be no gaps to signatures in the administration records. Occasional gaps were still evident, and a medication for one resident had not been signed for the last 10 days. Another resident’s medication was coded as being ‘refused’ in the morning, however the Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 11 prescribed direction was for it to be given at night. Staff need to make sure they record the amount of variable dosage medication given. The Controlled Drugs Register was appropriately recorded, with the exception of one occasion where there were not two staff signatures. Residents spoken with confirmed that staff treat them with respect and ensure their privacy and dignity is maintained. Staff record how each resident wishes to be addressed in the care files. Only one bedroom is currently shared. The two residents prefer not to have screening in place and staff provide assistance in the privacy of the en-suite. Personal care is carried out in private in the resident’s bedroom. Medical examination or treatment takes place either in bedrooms or the home’s treatment room on the ground floor. Fourteen residents currently have telephones in their bedrooms, with their own numbers, and they are separately billed. A pay telephone is available. Mail is given unopened to residents unless an agreement has been made to keep it for their relatives to deal with. There are systems of labelling clothing and named laundry baskets to ensure residents wear their own clothes. The inspector recommended that inventories of clothing and possessions be introduced. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are offered daily social stimulation. Residents are supported to maintain contact with relatives, friends and the local community. Residents are encouraged to make choices and decisions in daily living. There is a varied menu with choice of meals. Issues relating to individual residents eating requirements need to be followed up. EVIDENCE: Residents have their social needs assessed and recorded in social care plans. Summary life histories are also documented. A social activities programme is drawn up every month and copies are provided to residents. A good range of daily activities and outings is offered. In recent months two of the homes regular visiting activities people have left. Some residents commented on missing them. Activities were being provided daily by staff as evidenced from entries in the social diary. The home also uses Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 13 other external visitors who carry out art classes, aromatherapy and film shows. Residents confirmed they were aware of activities and that there was something going on every day. Outings since the last inspection included a Garden Centre, shopping in the city centre, supermarket and Byker, the Discovery Museum, local pub, and Pets Corner. A file of photographs of events and outings is kept. The home has an open visiting policy and visitors are offered hospitality. Residents can choose whom they wish to see and receive visitors in either communal areas or the privacy of their bedroom. Relatives and friends are encouraged to be involved and support individuals, for example invitation to care reviews and social events. Residents are encouraged to maintain contact with the local community and use amenities. Local clergy visit individual residents. The home has a volunteer who visits weekly and carries out social activities. Wherever possible residents continue to manage their own finances, or be assisted by relatives or solicitors. No staff within the company or home has Appointeeship responsibility for any resident’s financial affairs. Cash can be held for safekeeping. Agreement is reached before admission regarding the extent of personal possessions to be brought into the home. Many residents had personalised their rooms with items from home. Information on advocacy services is available. In practice residents relatives advocate on their behalf where necessary. The home has a policy on access to personal records. Records are kept to verify where information is provided and residents/relatives have read records. A 3-week cycle of summer menus had recently been introduced. These demonstrated a good variety and choice of meals. Snack suppers needed to be included. Residents were meeting with catering staff later this week to discuss meals. The majority of residents spoken with told the inspector that the food was good. Two ladies gave examples of requesting alternatives to the menu and these being readily provided. Negative comments were made about ‘thin’ soup and tough meat. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 14 The daily menu is written up on a white board in the dining room. Residents are asked at the meal which option they wish to have. Some residents choose to take meals in their rooms. The inspector dined with residents at lunch. Dining tables were nicely set and condiments were provided. Hot and cold drinks were offered during the meal. The meal was unhurried and staff were fairly attentive without being intrusive. Observations were relayed to the manager to follow up. These were: • • A resident with physical disability experiencing difficulty in eating her meal. There was no adapted cutlery/crockery/plate-guard. Food and drink issues for a diabetic resident. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 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 the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents understand how to make a complaint. There are procedures to protect residents from abuse, however staff training needs to be organised. EVIDENCE: The home has a clear complaints policy. Residents told the inspector that they were aware of how to make a complaint. Most said they would talk to the manager if there were anything they were unhappy about. No complaints have been received by the home or made to the CSCI in the period since the last inspection. Complaints records are maintained. At the previous inspection a recommendation was made that the home should keep details of all complaints received. This had been actioned. The home has procedures regarding prevention of abuse, protecting vulnerable adults and whistle blowing (informing on bad practice). All staff have not however received training on abuse and protection. This needs to be arranged to make sure staff have full understanding. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 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 the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The building is maintained to a good standard and kept clean and hygienic. EVIDENCE: The home was refurbished in 2004. All areas of the building seen were clean, nicely decorated and furnished and suitably equipped. A rolling programme of works is in place and records are kept of all maintenance. The grounds are very attractive and residents make use of the gardens in fine weather. The home has policies and procedures on infection control. Appropriate hand washing facilities and protective gloves and aprons are provided. Staff have received training on control of infection. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Good staffing levels are provided to meet the needs of residents. Staff are supported to gain care qualifications. The recruitment process needs some improvement. A range of staff training is provided appropriate to caring for older people. EVIDENCE: At the time of the inspection there were 35 residents, 31 category Older People and 4 category Older People with Dementia. There was good care staffing levels of 5 carers across the waking day and 3 carers at night. A good level of weekly ancillary staff hours is provided. Approximately 50 of carers have achieved NVQ qualifications in care. A further 2 staff are currently studying and one has recently enrolled for the training. The home has no current staff vacancies. The staff team has stabilised in the period since the last inspection through further recruitment. This has included recruiting staff from overseas. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 18 A sample of staff recruitment files was examined. Photographs and proof of identification were not available on file. Appropriate information, for example application forms, interview assessment and Criminal Records Bureau checks was maintained. References were usually obtained form suitable sources, including last employer where applicable. However one staff member was employed on the basis of two character references; whilst there was no previous employment an educational reference could have been sought. At the last inspection there was an outstanding requirement that all care staff must be provided with training in caring for people with dementia. Eight staff to date had completed this training and a further two sessions was planned for June 2006. It was previously recommended that the staff training programme should be brought up to date. This had not been fully actioned. Training provided in the past year included safe handling of medication, dementia, food hygiene, law/legislation, customer care, dietary needs, supervisory development, health and safety, and risk assessment. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There is a suitably experienced manager who is studying for a management qualification. Systems to monitor the quality of the service are to be improved by introducing audits. The home safeguards resident finances. There is good compliance with health and safety requirements. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 20 EVIDENCE: At the previous inspection a requirement was made that the Registered Manager must be provided with consistent supernumerary hours to fulfil management responsibilities. This had been actioned. The Manager, Mrs Barbrook is currently undertaking the Registered Manager Award course and expects to complete by the end of 2006. The home has methods to monitor the quality of the service, including surveys, meetings and monthly visits and reports by a senior manager. At the previous inspection a recommendation was made that audits should be introduced as part of the quality monitoring system. This had not been actioned and further advice was given. The Manager agreed that initial audits could include care records/plans, medication and health and safety. The majority of comments received from residents during the inspection were very positive about living in the home. They were complimentary about staff and in the main, described being well looked after. A number of residents had formed friendships with one another and were chatting together in lounges and bedrooms. Ten residents completed Commission for Social Care Inspection surveys. Each said they had received enough information about the home before moving in, and had received a contract. They said they always or usually received the care and support they need, including medical support, that staff listen and act on what they say, and staff are available when they need them. They confirmed activities are arranged that they can take part in. A minority said they always like the meals, whilst others replied ‘usually’ or ‘sometimes’. Residents indicated they know how to make a complaint. Each said the home is always fresh and clean. Additional comments were made as follows: “I never thought that I was so fortunate to be in Craghall”. “I enjoy staying here, all staff and residents are kind”. “Since I came I have been very happy and contented here. All staff have been very nice and always around to help”. “Received quite a lot of information when I came for a day assessment” “Staff are wonderful. Staff will help when necessary. Asked for something, think the staff forget sometimes. Cook and staff do try, too many chips”. “This home is classed as residential and I expected more people like me, who I could speak to, to be here. Would prefer to have more activities. Sometimes meals not hot enough when I receive them in my room”. “I am quite happy with the support given”. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 21 Seven relatives/visitors completed Commission for Social Care Inspection surveys. Each said they were welcomed into the home, can visit in private, and are kept informed of important matters affecting their relative/friend. Six said they are consulted about their relative’s care and one said they were not always. Six indicated there was always sufficient staff on duty and one felt there was not. Two were not aware of the home’s complaints procedure. None had ever made a complaint. Some were not aware of forthcoming inspections (the majority of inspections are now unannounced), or the availability of inspection reports. Each was satisfied with the overall care provided. Additional comments were made as follows: “We are very happy with the care my mother receives at Craghall. My only complaint is in relation to the activities programme that seldom seems to happen even though a printed programme is given to residents each month. No explanation is given to residents when activities fail to materialise”. “Staff are great and even let me sit with my grandma during breakfast. I really appreciate the time staff spend with my grandma (for example I came in today to find a member of staff playing dominoes with her and her friend), and there are always new photos of my grandma showing where she’s been on trips. I’m always made welcome, everyone says hello when I come in and has a word. I really enjoy coming. Christine the manageress really cares and it shows throughout the home”. Responses and comments from surveys were relayed to the manager. Records are kept of residents cash held for safekeeping and any transactions. These were suitably recorded with two signatures and receipts are obtained. Regular balance checks are carried out. A spot check of cash, balances and receipts was correct. There was plenty of evidence of personal spending, for example toiletries, clothing, hairdressing, newspapers, and outings. At the previous inspection there was an outstanding requirement that monthly checks of emergency lighting and fire equipment must be conducted and recorded. This had been actioned. All other fire safety checks, tests and instructions to staff were up to date. The home has service agreements in place for equipment. Accident reporting was well recorded and includes follow up entries and analysis to identify any patterns. Staff receive training in health and safety and safe working practices. The manager and designated health and safety officer have completed relevant training, including risk assessment. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 22 A new health and safety policy and risk assessments for the environment and tasks were being introduced. Risks associated with individual resident vulnerability are carried out. An example was seen for oxygen storage. The health and safety officer keeps good records relating to health and safety in the workplace, risk assessment, policies and procedures, environmental health, service checks, contents of first aid boxes, information on gas, water, and electric supplies, and water temperatures. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 24 YES 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 OP7 Regulation 15 (a) Requirement Timescale for action 17/08/06 2. OP8 12(1) 3. OP9 13(2) All residents must have care plans that address assessed needs. (b) Daily reports must link to care plans. Residents with continence 17/06/06 management needs must have: (a) Proper assessment of their needs, (b) Specific care plans to promote continence, (c) Toileting regimes and programmes that are monitored and adapted accordingly. (a) There must be no 17/05/06 unexplained gaps to signatures within medication administration records. (Outstanding Requirement) (b) Staff must check the prescribed direction time of medication. (c) The amount of variable dosage medication given must be recorded. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 25 4. 5. OP18 OP29 13(6) 19, Schedule 2 Staff must be provided with training on abuse and protecting vulnerable adults. (a) Staff recruitment files must include photograph and proof of identification (b) References must be sought from suitable sources 17/08/06 17/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP10 OP15 OP30 OP33 Good Practice Recommendations Inventories of clothing and belongings should be introduced. (a) Snack suppers should be included in menus (b) Issues from meal observations should be followed up. (Outstanding Recommendation) The staff training programme should be brought up to date. (Outstanding Recommendation) Audits should be introduced as part of the quality monitoring system. Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Craghall Residential Home DS0000039863.V289712.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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