Inspection on 15/02/06 for Cranmore House

This inspection was carried out on 15th February 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

Cranmore House 12/06/07

Cranmore House 25/05/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Cranmore House 107 Sutton Road Erdington Birmingham West Midlands B23 5XB Lead Inspector Jane Walton Unannounced Inspection 15th February 2006 10:30 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 Cranmore House DS0000064262.V283946.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. Cranmore House DS0000064262.V283946.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cranmore House Address 107 Sutton Road Erdington Birmingham West Midlands B23 5XB 0121 373 9784 0121 373 9784 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) Dr Jayshree N Patel Mrs Hemlata Patel, Mr Ullas Ambalal Patel, Mr Mukesh Patel, Mrs Dipika Patel, Mr Kirit Patel, Dr Jivantika Patel, Ms Narendra Patel Mrs Thomasine Elaine Singer Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Cranmore House DS0000064262.V283946.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. That the home can accommodate up to 22 residents for reasons of old age (OP) excluding all other categories. That until the Commission is in receipt of a clear enhanced CRB check for Dr Jivantika Patel she must not enter the registered premises. That the owners carry out an audit of all bedroom facilities including carpets and furnishings and replace any item no longer fit for use by October 2006 Audit of all external window and door frames. Repair or replace those identified and specifically all ground floor bedrooms by October 2006. Floor covering to the dining area and by the kitchen is replaced by June 2006. That the registered person submits plans by October 2006 for improving the laundry location and facilities. 29th November 2005 Date of last inspection Brief Description of the Service: Cranmore House is a large Victorian detached property on Sutton Road in Erdington. It is situated a few yards from the crossroads with the Chester Road and the Yenton Public house and the Chester Road shopping centre. Public bus services run past the home and Chester railway station is within easy walking distance. Local amenities are close by. The property has an extension to provide accommodation for twenty-two older people. Care facilities are provided on the ground and first floor, and the second floor is used for administration purposes. The ground floor has one large and one small lounge, kitchen, dining room, laundry, toilet and bathroom facilities. There are four single and two double bedrooms situated on this floor. The first floor has ten single and two double bedrooms, together with bathing/shower facilities and toilets. None of the bedrooms has en suite facilities. There is a passenger lift to access the first floor. Parking is available to the front of the building, and a large mature garden at the rear, with patio and a lawn is accessible for the residents. Cranmore House DS0000064262.V283946.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of Cranmore House for the inspection year 2005/6, and was Unannounced. The inspection was carried out over eight hours in February 2006. The home had been under new ownership for 2 weeks prior to this inspection. There were 20 residents in the home, with 1 in hospital, and the inspector was able to speak to 8 of them. 4 members of staff were spoken to; the Deputy manager was present throughout the inspection and the Responsible Individual for part of it. Care Plans and a sample of other records were examined. What the service does well: What has improved since the last inspection? What they could do better: A comprehensive and up to date Statement of Purpose and Service User Guide is needed to supply information to prospective residents and their families. All prospective residents must have a full pre- admission assessment to ensure that the home is able to meet all of the identified needs. All residents require a care plan that identifies needs and explains the management needed to meet them. The medication management in the home requires improvement. All staff that administer medicines must have the appropriate approved safe handling of medicines training, and apply it to their practice. A regularly reviewed menu catering to the tastes of the residents must be available. At the time of the sale of the Home, several requirements were made regarding auditing and actioning maintenance of the building issues. Cranmore House DS0000064262.V283946.R01.S.doc Version 5.1 Page 6 These included, improving the laundry facilities, replacing floor coverings in several areas of the home, and the re decoration and refurbishment of several areas of the home. There are currently only 40 of care staff trained to NVQ level 2 and to meet the standard at least 50 are required. A formal Quality Assurance programme needs to be implemented to enable the staff to monitor and improve on the services it offers to residents. Formal staff supervision needs to be carried out at least 6 times per year for each individual, and a record kept. Weekly fire alarm tests must be carried out and recorded. All fire records must be available for inspection upon request. Wheelchairs must not be used to transport residents unless the footplates are in place, as this poses a potential risk to the resident. 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. Cranmore House DS0000064262.V283946.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 Cranmore House DS0000064262.V283946.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): 1, 3, 5 Prospective service users require up to date information to enable them to make an informed choice whether to live in the home or not. The needs of individual residents are not always assessed and met, therefore placing them at potential risk. EVIDENCE: The current Service Users Guide and Statement of Purpose have not yet been amended to reflect the changes in ownership of the home. There had been no new admissions to the home since the new owners and new deputy manager had been in post. There was evidence that pre admission assessments for existing residents had not always been completed and information was sometimes sketchy. A discussion with the deputy manager revealed that she has plans to introduce a more comprehensive pre admission format, and the form for this was evidenced. Prospective residents will be visited in hospital if necessary, or invited to the home for part of a day, where the resident and their family will be involved in the assessment to ensure that the home is able to meet the identified needs. There were 2 residents in the home who are younger than the ages stated on the Registration Certificate. Both residents had been admitted prior to the change of ownership of the home, but there Cranmore House DS0000064262.V283946.R01.S.doc Version 5.1 Page 9 was no evidence that steps had been taken to identify their specific needs and how these needs would be met. Cranmore House DS0000064262.V283946.R01.S.doc Version 5.1 Page 10 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, 10 Residents’ basic care needs are known by staff, however more detailed care plans are needed to ensure that their health needs are being fully met. The systems for the administration of medication were varied leading to a potentially poor outcome for some service users. Residents are treated with respect. EVIDENCE: All residents were seen to have a care plan in place, and three of these were examined. Two of the care plans contained very little information about the resident, where a need had been identified there was no information as to the management required. There was documented evidence of input from district nurses, optician and chiropodist. The corresponding daily records were very brief and did not accurately reflect the life of the resident whilst living in the home. One care plan had been rewritten in the new format that the deputy manager intends to introduce for all residents. The plan gave a more holistic view of the residents’ needs, including risk assessments that had been carried out and information of the management required. A record is kept of visits by the GP and provision made to record visits from other health professionals. Staff Cranmore House DS0000064262.V283946.R01.S.doc Version 5.1 Page 11 spoken to were able to demonstrate a good knowledge and understanding of the residents basic needs. Residents spoken to said that they felt they were treated with respect by the staff, who were observed to interact well with the residents. The home has some double occupancy bedrooms that currently do not have adequate screening to ensure that the privacy and dignity of the residents is observed. An audit of the medication management in the home was carried out. The medicines are currently stored in a locked cabinet in a locked walk-in cupboard. Access to the cabinet is awkward, and the space in the cupboard is very limited. There were no residents having controlled drugs. There was a small fridge for the storage of medicines requiring refrigeration, however, the temperature of 11 degrees centigrade was too warm, and did not meet the drug manufacturers guidelines. Daily fridge temperatures are not currently recorded. The home uses a Monitored Dosage System (MDS) in the main, with a few medicines being supplied in individually labelled boxes. Photocopies of current prescriptions were kept with the Medicine Administration Record (MAR) charts, for cross-referencing purposes, and a photograph of each resident was present, for safety and ease of recognition. Audits of two individual residents’ MAR charts revealed that there were several gaps with no signatures. There were two instances on one day where medicines had been signed as given to a resident, but the tablets were still in the MDS cassette. One boxed medicine could not be audited because the prescription was for 1 or 2 tablets to be given, and there was no indication on the MAR chart whether 1 or 2 had been administered. The third MAR chart examined showed that all counts were correct and there were no anomalies or errors. Cranmore House DS0000064262.V283946.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): 14, 15 The flexibility of daily practices enables service users a degree of choice and control. There is no set menu provided so that it was not possible to accurately identify if a well balanced nutritious diet is provided. EVIDENCE: One resident was observed to be waiting in the hallway wearing her outdoor coat. When asked she said, “ I am going to see my brother who is in hospital at the moment”. Staff informed that the resident was very independent and often went out on her own. Bedrooms seen during the course of the inspection were seen to be furnished with residents’ own personal items. Meals for residents are served in the dining room, which is spacious enough to accommodate all residents at the same time. There is currently no set rolling menu, so it was not possible to assess accurately whether a balanced and nutritious diet is offered to the residents, although residents stated that they had a good variety of food served, and they generally liked the food. The meal at this lunchtime was faggots, mashed potatoes and mixed vegetables followed by a shop bought apple pie or jam sponge served with custard. The inspector joined the residents for tea at 4.30 pm, in the dining room when a range of sandwiches, tomato soup, cake and tea and coffee were served. One resident had tinned peaches that she had requested. All residents were offered second helpings. There were no tablecloths or serviettes on the tables, Cranmore House DS0000064262.V283946.R01.S.doc Version 5.1 Page 13 and the placemats were observed to be very worn and some were warped so that plates did not sit flat. The dining chairs are new and were comfortable to sit on. The deputy manager stated that she intends to introduce a 4-week rolling menu that will be devised with input from the residents. Cranmore House DS0000064262.V283946.R01.S.doc Version 5.1 Page 14 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, 18 There is a complaints procedure so that residents and their relatives may make a complaint if they wish to do so. The procedure for Adult Protection follows local guidelines and the policy ensures residents are protected from abuse. EVIDENCE: Since her recent appointment, the deputy manager is reviewing the policies and procedures for the home. There have been no complaints made about the home since the change of ownership took place. There was no complaints log in place. The deputy manager demonstrated a very good understanding of adult protection procedures, and was familiar with the Birmingham Multi Agency Guidelines for Adult Protection. Cranmore House DS0000064262.V283946.R01.S.doc Version 5.1 Page 15 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, 25, 26 Current environmental issues and general maintenance standards do not ensure that residents have safe and comfortable surroundings to live in. EVIDENCE: Prior to the change of ownership there were a number of issues relating to the environment of the home that required addressing. Some of these requirements have been made conditions of the registration of the providers. During the short period since the new owners took over, a few of the outstanding requirements have been addressed. The Responsible Individual informed the inspector that a programme of repairs and refurbishment is currently being drawn up. At the time of the inspection the home appeared generally clean, pleasant smelling and hygienic. Cranmore House DS0000064262.V283946.R01.S.doc Version 5.1 Page 16 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, 30 The numbers of care staff meets the current residents’ needs. Extra hours for kitchen duties would enhance the standard of menu offered to residents. Increased numbers of care staff qualified to NVQ2 would enhance the safety of residents. EVIDENCE: The current Registered Manager of the home was also the owner until the new Providers took over at the beginning of February 2006. The manager currently works approximately 10 hours per week to support the newly appointed Deputy Manager. The Responsible Individual informed the inspector that their intention is to put forward the Deputy Manager to be the Registered Manager after a suitable period has elapsed. The Responsible Individual was advised to employ the services of a consultant to support the deputy in the absence of the current registered manager. Staff rotas indicated that there are 3 carers on duty in the morning and 2 in the afternoon/evening, until 8pm. One of the carers is a senior. Night shifts run from 8pm – 8am and there are 2 waking carers on duty, with the deputy manager being available on call. There are currently a total of 15 care staff, 6 of whom are trained to NVQ level2. This number is below the requirement needed to meet the standard. At the time of the inspection, the staff to resident ratio appeared adequate to meet the needs of the current residents. The manager must ensure that regular assessments of residents needs are monitored and that the staffing levels remain adequate to meet them. There is also a part time cook, cleaner and handyman employed. Extra help in the kitchen would ensure that the Cranmore House DS0000064262.V283946.R01.S.doc Version 5.1 Page 17 proposed 4 week rolling menu could be adhered to. Current domestic hours of 15 per week may not be sufficient to ensure that all the necessary monitoring of domestic duties can be carried out. No new staff had been recruited since the change of ownership, so standards of recruitment practice could not be assessed at this inspection, and will be inspected at the next. The manager is currently advertising for more staff. The deputy manager has compiled a matrix to identify the statutory training needs of the staff. A programme has been drawn up, and is to be implemented shortly. There is currently no formal Induction or foundation training programmes in place.5 Cranmore House DS0000064262.V283946.R01.S.doc Version 5.1 Page 18 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, 36, 37, 38 A robust system for the management of residents’ personal allowances is in place. Current management experience in the home is limited and further measures need to be taken in order to ensure the protection and safety of residents. The lack of a Quality Assurance programme impacts on the quality of life of the residents. Improved training and the implementation of staff supervision would help to ensure the health, safety and wellbeing of residents were promoted and protected. EVIDENCE: The current Registered Manager of the home was also the owner until the new Providers took over at the beginning of February 2006. The manager currently works approximately 10 hours per week to support the newly appointed Deputy Manager. The Deputy Manager worked previously at a care home in the role of deputy/senior care. She currently has NVQ3 in care, and is undertaking NVQ4 in Care. She stated that she hopes to commence NVQ4 in Management in September 2006. The Responsible Individual informed the Cranmore House DS0000064262.V283946.R01.S.doc Version 5.1 Page 19 inspector that their intention is to put forward the Deputy Manager to be the Registered Manager after a suitable period has elapsed. The Responsible Individual was advised to employ the services of a consultant to support the deputy in the absence of the current registered manager. There is currently no formal Quality Assurance programme in the home, although the Deputy manager informed the inspector that residents’ views are sought in an informal manner. Small amounts of residents’ personal monies are handled by the home. Records were examined and an audit demonstrated that all balances were correct and receipts are kept of any items purchased. It was recommended that the receipts be numbered sequentially for ease of the audit process. The Deputy Manager has not yet implemented formal staff supervisions, but indicated that she was aware of the need to carry out supervisions at least 6 times per year and keep an appropriate record. All the policies and procedures that are to be used in the home are currently under review, and will be amended accordingly. Examination of the fire alarm testing records indicated that the weekly fire alarms had not been undertaken for several weeks. The Deputy Manager was aware that regular weekly tests must be carried out and documented. The remaining records for fire safety checks were not available for inspection. Two wheelchairs, which staff informed the inspector, were in daily use were parked outside the laundry. One of the chairs was not fitted with footplates. For safety reasons, the footplates must be located and fitted. Cranmore House DS0000064262.V283946.R01.S.doc Version 5.1 Page 20 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 2 X 2 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 2 3 STAFFING Standard No Score 27 3 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 1 1 2 Cranmore House DS0000064262.V283946.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 5 Requirement The Registered Person must ensure that a fully amended Statement of Purpose and Service users Guide that accurately reflects the services offered by the home is available for all current and potential residents. All residents must have a comprehensive pre- admission assessment undertaken to ensure that the home can adequately meet their needs. A variation for registration must be submitted in relation to the 2 residents identified who are currently out of category of registration. All residents must have a care plan that accurately reflects their current needs, and states the management required to meet those needs. Care plans should contain actions required by staff following risk assessments. Care plans must be reviewed monthly. Daily records should accurately DS0000064262.V283946.R01.S.doc Timescale for action 31/07/06 2 OP3 14 (1,2) 01/05/06 3 OP7 15 31/05/06 Cranmore House Version 5.1 Page 22 4 OP9 13(2) reflect the life of the resident in the home. The Registered Person must ensure that regular weekly audits of the medication management in the home are carried out. The temperature of the drugs fridge must be recorded daily, and must not exceed 8 degrees centigrade. 01/05/06 5 6 OP10 OP15 12(4)(a) 12(2,3) The current storage of medications should be reviewed so as to allow easy access. Adequate privacy screening must 30/06/06 be provided in all double occupancy bedrooms. A regularly reviewed menu, 01/04/06 offering a choice of meals must be available for residents. A quality control measure must be put in place for customer satisfaction of meals. Place mats that are fit for purpose must be provided in the dining room. The toilet seat in the assisted bathroom needs replacing, and the extractor fan needs to be repaired. This requirement dates from the pre-sale site visit undertaken on 05/07/05. The smokers’ lounge requires suitable ventilation to prevent smoke drifting into the kitchen and dining room. This requirement dates from the pre-sale site visit undertaken on 05/07/05. The dining room requires new carpet tiles and furniture. DS0000064262.V283946.R01.S.doc 7 8 OP15 OP25OP19 16 13(4) 01/05/06 01/05/06 9 OP25OP19 13(4) 31/07/06 10 OP25OP19 13(4) 31/10/06 Cranmore House Version 5.1 Page 23 11 OP25 OP19 13(4) This requirement dates from the pre-sale site visit undertaken on 05/07/05. The lino flooring outside the kitchen is cracked and needs to be replaced. This requirement dates from the pre-sale site visit undertaken on 05/07/05. Plans must be submitted to the Commission for improving the laundry location and facilities. This requirement is a condition of registration. Floor covering to the dining area and by the kitchen must be replaced by June 2006. This requirement is a condition of registration. The owners must carry out an audit of all bedroom facilities including carpets and furnishings and replace any item no longer fit for use by October 2006. This requirement is a condition of registration. An audit of all external window and doorframes must be carried out. Repair or replacement of those identified and specifically all ground floor bedrooms to be carried out by October 2006. This requirement is a condition of registration. Suitable locks will need to be fitted to bedroom doors that allow service users privacy but can be accessible for staff in an emergency. The Registered Person must ensure that there are at least 50 of care staff trained to NVQ level 2. DS0000064262.V283946.R01.S.doc 31/05/06 12 OP19 13(4) 31/10/06 13 OP25OP19 13(4) 30/06/06 14 OP25OP19 13(4) 31/10/06 15 OP25OP19 13(4) 31/10/06 16 OP25OP19 13(4) 31/10/06 17 OP28 18(1)(a) 01/04/07 Cranmore House Version 5.1 Page 24 18 OP30 19 OP31 20 OP33 12(1)(a,b) The Registered Person must 18(1)(a,c) ensure that there is a formal induction and foundation programme for all new staff. 9(1) The proposed registered 2(b)(i) manager must have the qualifications, skills and experience necessary for managing the care home, and at least 2 years experience in a senior management capacity in the managing of a relevant care setting within the last 5 years. 24(1)(a,b) A formal Quality Assurance system must be implemented within the home, to monitor, maintain and improve the services offered. 18(2) (Outstanding since 08/04/05) Formal recorded supervision for all staff must take place at least 6 times per year. (Outstanding since 08/04/05) Policies and procedures must be reviewed to ensure they meet all current guidelines and include both an issue and a review date. Regular weekly fire alarm tests must be carried out and documented. All other fire records must be available for inspection upon request. All wheelchairs used for the transportation of residents in the home must have footplates fitted unless a risk assessment has been carried out that indicates otherwise, for an individual resident. 31/05/06 30/09/06 31/10/06 21 OP36 31/05/06 22 OP37 17 31/05/06 23 OP38 23(4) 01/05/06 24 OP38 12(1)(a) 01/05/06 Cranmore House DS0000064262.V283946.R01.S.doc Version 5.1 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cranmore House DS0000064262.V283946.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Cranmore House DS0000064262.V283946.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!