Inspection on 05/07/04 for Cranmer

Care Homes For Adults (18 – 65)Cranmer237 Coleman Street Whitmore Reans Wolverhampton West Midlands WV6 0RGAnnounced Inspection5th July 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: • Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. Cranmer Announced Inspection 5.7.04ESTABLISHMENT INFORMATION Name of establishment Cranmer Address Cranmer, 237 Coleman Street, Whitmore Reans, Wolverhampton, West Midlands, WV6 0RG Email address Tel No: 01902 747945 Fax No: 01902 712610Name of registered provider(s)/company (if applicable) Milbury Care Services Limited Name of registered manager (if applicable) Mr Kenneth Gofton Type of registration Care Home No. of places registered (if applicable) 8Category(ies) of registration, with (number of places) Learning disability (8), Old age, not falling within any other category (8) Registration number E080000157 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 19th March 2003 yes NO 07/02/04 If Yes refer to Part CCranmerPage 1 Cranmer Announced Inspection 5.7.04 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 3 5th July 2004 08:00 am Mr Ian Harris 073476 ID CodeName of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionCranmerPage 2 Cranmer Announced Inspection 5.7.04 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspector’s Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 – 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Provider’s Response Provider’s Comments Action Plan Provider’s AgreementCranmerPage 3 Cranmer Announced Inspection 5.7.04 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Cranmer. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: • Inspection methods used • Key findings and evidence • Overall ratings in relation to the standards • Compliance with the Regulations • Required actions on the part of the provider • Recommended good practice • Summary of the findings • Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.CranmerPage 4 Cranmer Announced Inspection 5.7.04 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Cranmer, 137 Coleman Street, is a care home providing accommodation and personal care to eight adults with learning disabilities. It is one of a group of homes owned by Milbury Community Services Ltd. The home is located in the Whitmore Reans area of Wolverhampton. It is close to local amenities and on a main bus route into the city. All bedrooms are single occupancy and are individually decorated to a high standard. The lounge and dining areas are comfortable, homely and well furnished.CranmerPage 5 Cranmer Announced Inspection 5.7.04PART ASUMMARY OF INSPECTION FINDINGSInspector’s Summary (This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) Choice of Home (Standards 1–5) 5 of the 5 standards assessed were met. Individual Needs and Choices (Standards 6–10) 3 of the 5 standards assessed were met 2 standards were not assessed at this inspection. Lifestyle (Standards 11–17) 7 of the 7 standards assessed were met. Personal and Healthcare Support (Standards 18–21) 3 of the 4 standards assessed were met 1 standard was not assessed at this inspection. Concerns, Complaints and Protection (Standards 22–23) 2 of the 2 standards assessed were met. Environment (Standards 24–30) 5 of the 7 standards assessed were met. In order to fully meet standards 26 and 29 a radiator cover must be provided in the ground floor bedroom and a call alarm system fitted to all the resident’s bedrooms. Staffing (Standards 31–36) 4 of the 6 standards assessed were met 2 standards were not assessed at this inspection. Conduct and management of the home (Standards 37–43) 3 of the 7 standards assessed were met 3 standards were not assessed at this inspection. In order to fully meet standard 39 a copy of the monthly regulation 26 visits to the home must be sent to the commission.CranmerPage 6 Cranmer Announced Inspection 5.7.04 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report, which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard Required actions Timescale for action 1 16.1 YA29 The registered manager must now give consideration to the installation of a call bell system appropriate to the assessed needs of service users living at the home. All staff must receive supervision at least six times per year in addition to regular day-to-day contact. Staff must have an annual appraisal with their line manager to review performance against their job description and agree career developments. The home states that this has been completed The home states that this has been completed2 18.2YA36Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCranmerPage 7 Cranmer Announced Inspection 5.7.04 CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). MET (YES/NO)CranmerPage 8 Cranmer Announced Inspection 5.7.04 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard * Requirement Timescale for action The registered manager must now give consideration to the installation of a call bell system appropriate to the assessed needs of service users living at the home. All staff must receive supervision at least six times per year in addition to regular day-today contact. 2 18.2 YA36 Staff must have an annual appraisal with their line manager to review performance against their job description and agree career developments. The home states that this has been completed The home states that this has been completed116.1YA29324YA39The registered manager is required to establish and maintain a process for the effective quality assurance and monitoring 01/09/04 systems together with an annual development plan. The registered person must ensure that the radiator in the ground floor bedrooms is covered or replaced. The home states that this has been completed423YA26CranmerPage 9 Cranmer Announced Inspection 5.7.04 The registered person must ensure that a copy of the monthly regulation 26 visits to the home are sent to the Commission. The registered person must ensure that all the staff receive copies of the General Social Council’s Code of practice The home states that this has been completed 01/08/04526618YA31RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling • Pre-inspection questionnaire • Records • Care plans / Care pathways • Meals • Activities • Other enter details here ‘Tracking’ care and support Group discussion with service users Individual discussion with service users Cranmer YES YES YES YES YES NO NO NO NO YES YES Page 10 Cranmer Announced Inspection 5.7.04 Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)YES YES YES YES YES NO YES NO YES 5 X X YES YES YES YES 17 X 5/07/04 08:00 4The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. “X” is used where a percentage value or numerical value is not applicable.CranmerPage 11 Cranmer Announced Inspection 5.7.04Choice of HomeThe intended outcomes for the following set of standards are: • • • • • Prospective service users have the information they need to make an informed choice about where to live. Prospective service users’ individual aspirations and needs are assessed. Prospective service users know that the home they choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to ‘test drive’ the home. Each service user has an individual written contract or statement of terms and conditions with the home.Standard 1 (1.1 – 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users’ guide. 386.00 388.00 Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 3 Key findings/Evidence Standard met? The home has a very good statement of purpose that the Care Manager has recently revised. The statement of purpose has been designed to incorporate the service users guide.Standard 2 (2.1 – 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? All the service users are admitted to the home following a full multi-disciplinary assessment. An initial care plan is produced from the assessment and is used as a basis for the care that is provided.CranmerPage 12 Cranmer Announced Inspection 5.7.04 Standard 3 (3.1 - 3.10) The registered person can demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The home provides very detailed care plans for each resident, which is reviewed on a regular basis. There is a care plan on every resident’s individual file to show that where necessary, special services are obtained to met the resident’s individual needs.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? Prospective residents are encouraged to visit the home prior to admission. An introductory visit is always offered to prospective residents and their family.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 3 Key findings/Evidence Standard met? The home has a very good Life style agreement, which has recently revised and meets the National Minimum Standard.CranmerPage 13 Cranmer Announced Inspection 5.7.04Individual Needs and ChoicesThe intended outcomes for the following set of standards are: • • • • • Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept.Standard 6 (6.1 – 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? The home provides a very good care plan for each resident which is based on the initial assessment, these Care Plans are drawn up by the staff in consultation with the residents and their families. The care plans are reviewed every month or before if necessary.Standard 7 (7.1 – 7.7) Staff respect service users’ right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? There was evidence to show that the Staff at the home involve the residents in decision making at house meetings. Also the key-worker’s encourage residents on an individual basis to be involved in decisions regarding their daily activities.CranmerPage 14 Cranmer Announced Inspection 5.7.04 Standard 8 (8.1 – 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? The residents are encouraged by their key-workers to be involved in the day -to day running of the home as much as possible. The residents make decisions regarding social activities, menus, outings and decoration of the home.Standard 9 (9.1 – 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service user’s individual Plan and of the home’s risk assessment and risk management strategies. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 10 (10.1 – 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the home’s written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.CranmerPage 15 Cranmer Announced Inspection 5.7.04LifestyleThe intended outcomes for the following set of standards are: • • • • • • • Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate, personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes.Standard 11 (11.1 – 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? The residents care plans reflect that service users are encouraged to be involved in a wide range of independent living skills activities.Standard 12 (12.1 – 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 4 Key findings/Evidence Standard met? The residents are encouraged to continue to attend Adult Training centres and local colleges and are involved in a wide range of activities. The staff are to be commended for their commitment in this area.CranmerPage 16 Cranmer Announced Inspection 5.7.04 Standard 13 (13.1 – 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 4 Key findings/Evidence Standard met? The staff are to be commended for the support that they provide to enable the residents to engage in a wide range of community activities at weekends. The home has the use of its own transport and residents visit shopping centres, parks and outings.Standard 14 (14.1 – 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? There is good evidence on file to show that residents are encouraged to choose from a wide range of leisure activities both within and outside of the home.Standard 15 (15.1 – 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 4 Key findings/Evidence Standard met? The staff are to be commended for the way they assist residents to maintain contact with their relatives by arranging meetings and contacting their relatives. Visitors are made welcome at the home and family and friends are invited and attend parties and celebrations.CranmerPage 17 Cranmer Announced Inspection 5.7.04 Standard 16 (16.1 – 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The home has a very relaxed and happy atmosphere and it was noted that there was good interaction between staff and residents. All the activities and mealtimes are organised to meet the individual needs of the residents.Standard 17 (17.1 – 17.9) The registered person promotes service users’ health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 4 Key findings/Evidence Standard met? From observations made and the comments received by the residents who could express themselves in a meaningful way confirmed particular attention is given to residents individual preferences in regard to the food provided in the home. All the comments regarding the quality, quantity and variety of the food and meals was highly complimentary. It was noted that residents also visit local restaurants, pubs and obtain take-a-way meals on occasions.CranmerPage 18 Cranmer Announced Inspection 5.7.04Personal and Healthcare SupportThe intended outcomes for the following set of standards are: • • • • Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish.Standard 18 (18.1 – 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users’ privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? All staff are aware of the need to provide sensitive care and to maintain the residents privacy and dignity. All these issues are clearly set out in the homes statement of purpose and aims and objectives. Also they are included in the homes induction programme and N.V.Q. training.Standard 19 (19.1 – 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 2X3 Key findings/Evidence Standard met? The Care Manager stated that the home is well supported by a local G.P. and all of the paramedical services when necessary. Where ever possible the residents, are encouraged to attend local Opticians, Dentists and G.Ps. Individual residents files indicate that all the residents are receiving appropriate attention.CranmerPage 19 Cranmer Announced Inspection 5.7.04 Standard 20 (20.1 – 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the home’s policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 4 Key findings/Evidence Standard met? The home has very good policies and procedures on all aspects of medication, which all of the staff are aware of. The medication is administered by means of a monitored dosage system, which appears to be working well. The home receives good support from the pharmacist, and all the staff that administer, medication have received training in the system.Standard 21 (21.1 – 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.CranmerPage 20 Cranmer Announced Inspection 5.7.04Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: • • Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 – 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X X 3 Key findings/Evidence Standard met? The home has good complaints procedure and the residents and relatives are made aware of the procedure through the statement of purpose and the Life style document. From discussions with residents and staff it was noted that the residents are confident that the residents key-worker would assist residents if they wanted to complain. Also the home has developed appropriate material to assist service users with their complaints.CranmerPage 21 Cranmer Announced Inspection 5.7.04 Standard 23 (23.1 – 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX3 Key findings/Evidence Standard met? The home has very good policies and procedures regarding the Prevention of Abuse, Restraint, Dealing with Aggressive Behaviour and a Whistle Blowing policy.CranmerPage 22 Cranmer Announced Inspection 5.7.04EnvironmentThe intended outcomes for the following set of standards are: • • • • • • • Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic.Standard 24 (24.1 – 24.13) The home’s premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users’ individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The home has a good rolling programme of maintenance and redecoration that maintains the home to a high standard.CranmerPage 23 Cranmer Announced Inspection 5.7.04 Standard 25 (25.1 – 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) – single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite YES NO NO 8 1 X X 8 XX X X X3 Key findings/Evidence Standard met? Seven of the bedrooms do not have en-suites and do not meet the new standards regarding size of rooms.CranmerPage 24 Cranmer Announced Inspection 5.7.04 Standard 26 (26.1 – 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 2 Key findings/Evidence Standard met? All the bedrooms are furnished to a high standard and all the bedrooms have been personalised by the residents, staff and their families. It was noted that the radiator in the ground floor bedroom needs a cover or be replaced with a low surface temperature radiator.Standard 27 (27.1 – 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? The home complies with the National Minimum Standards regarding numbers of bathrooms and toilets. All the bathrooms and toilets are fitted with appropriate aids to meet the needs of the residents.Standard 28 (28.1 – 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? The home complies with the Nation Minimum Standards in regards to the size of the communal rooms. The home offers a comfortable family type setting.CranmerPage 25 Cranmer Announced Inspection 5.7.04 Standard 29 ( 29.1 – 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the home’s stated purpose and the individually assessed needs of all service users. 2 Key findings/Evidence Standard met? It was noted that the residents with physical disabilities are not provided with a call alarm system in their bedrooms. However the home is fitted with other appropriate aids, which meet the resident’s needs.Standard 30 (30.1 – 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The home was found to be clean and tidy and free from odour. The home has good policies and procedures regarding infection control and all the staff have received training in food hygiene and one member of staff is undergoing intermediate food hygiene training. All staff are conscious of the dangers of cross infection.CranmerPage 26 Cranmer Announced Inspection 5.7.04StaffingThe intended outcomes for the following set of standards are: • • • • • • Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff.Standard 31 (31.1 – 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and other’s roles and responsibilities. 3 Key findings/Evidence Standard met? All the staff have received a copy of their job description and are aware of their role and responsibilities within the home through discussions at supervision and staff meetings.Standard 32 (32.1 – 32.6) Staff have the competencies and qualities required to meet service users’ needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? The home has a very good training programme, which provides N.V.Q. level 2-4 training.CranmerPage 27 Cranmer Announced Inspection 5.7.04 Standard 33 (33.1 – 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users’ assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 2 3 3 581 8 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided 200 300 81 581 Nursing X X XXX3 Key findings/Evidence Standard met? The inspection of the rotas and discussions with staff indicated that the home is adequately staffed. There is a good balance within the staff group, which includes experienced, mature and younger staff. There is also a good ethnic mix of staff.Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.CranmerPage 28 Cranmer Announced Inspection 5.7.04 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users’. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 2 Key findings/Evidence Standard met? Systems are in place for all staff to receive formal supervision with their line manager. All staff must receive supervision at least six times per year in addition to regular day-to-day contact. Staff must have an annual appraisal with their line manager to review performance against their job description and agree career developments.CranmerPage 29 Cranmer Announced Inspection 5.7.04Conduct and Management of the HomeThe intended outcomes for the following set of standards are: • • • • • • • Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self- monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service.Standard 37 (37.1 – 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. Key findings/Evidence This standard was not assessed at this inspection YES 0Standard met?Standard 38 (38.1 – 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspectionCranmerPage 30 Cranmer Announced Inspection 5.7.04 Standard 39 (39.1 – 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 2 Key findings/Evidence Standard met? The registered manager is required to establish and maintain a process for the effective quality assurance and monitoring systems together with an annual development plan. Service users surveys, satisfaction questionnaires and views of family and friends needs to be actively sought for the continuous self-monitoring of the service and carried out annually. It was noted that copies of the report of the monthly Regulation 26 visits to the home must be sent to the Commission.Standards 40 (40.1 – 40.6) The home’s written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection.Standard 41 (41.1 – 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? All the records and administrative procedures within the home were found to be well ordered and well maintained.CranmerPage 31 Cranmer Announced Inspection 5.7.04 Standard 42 (42.1 – 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The home has a good heath and safety policy and all staff are aware of their responcibilities regarding these issues and a number of staff have received trianing. Fire fighting equipment is well maintained and the systems are regularly checked. In regards to any accidents, they are all recorded in an appropriate record book.Standard 43 (43.1 – 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 3 Key findings/Evidence Standard met ? All the financial procedures within the home appear to be working well and it was noted that they are checked externally every month. The home has appropriate employers and public liability insurance and has provided a business and financial plan for the home.CranmerPage 32 Cranmer Announced Inspection 5.7.04PART C(where applicable) Condition CommentsCOMPLIANCE WITH CONDITIONSComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager DateIan Harris Teresa Wild 3 September 2004Signature Signature SignaturePublic reports It should be noted that all CSCI inspection reports are public documents.CranmerPage 33 Cranmer Announced Inspection 5.7.04PART DD.1PROVIDER’S RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Person’s comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 5 July 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleCranmerPage 34 Cranmer Announced Inspection 5.7.04 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection reportYESProvider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Provider’s Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here CranmerPage 35 Cranmer Announced Inspection 5.7.04 D.3 PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies. D.3.1 I Sue Draper of Cranmer confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of Cranmer am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Operations Manager 16.8.04 Sue DraperPrint Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.CranmerPage 36 - 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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