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Inspection on 14/02/06 for Cranwood

Also see our care home review for Cranwood for more information

This inspection was carried out on 14th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Service users have their needs assessed and their care plans reflect those needs. Personal care is provided in a way that respects the privacy and dignity of service users and the arrangements for the administration of medication and adult protection promote their safety. There are two activity co-ordinators who provide activities for service users on four days of the week. Practice in the home aims to give service users choice and to maximise their independence.

What has improved since the last inspection?

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Cranwood 100 Woodside Avenue Muswell Hill London N10 3JA Lead Inspector Karen Malcolm Unannounced Inspection 14th February 2006 11.55a 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 Cranwood DS0000033341.V286497.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. Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cranwood Address 100 Woodside Avenue Muswell Hill London N10 3JA 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) 020 8883 0563 020 8442 0075 London Borough of Haringey Ms Donna Hamilton Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may provide accommodation and personal care for up to 38 persons of either gender who are over 65 years of age (OP). The provider must undertake a programme of measures that will achieve compliance with National Minimum Standards for Older People Standards 19 to 26 - Environment, or those equivalent standards that may be published at the time, as required by Regulation 23(1)(a); 23(2)(a-p); 23(4)(c); and Regulation 16 (2)(c)(g)(j)(k) - by 1st April 2005. In order to promote the health and safety needs of service users living in Cranwood, the provider must ensure that the home complies with all requirements contained in relevant Health and Safety Legislation and further must undertake a programme of measures that will achieve full compliance with National Minimum Standards, or those equivalent standards that may be published at the time, as required by Regulation 23(1)(a); 23(2)(a-p); 23(4)(c); and regulation 16 (2)(c)(g)(j)(k) - by April 1st 2004. To provide intermediate care to a maximum of 9 of the 34 service users of either gender, seven of whom must be 65 years of age or older. Two of these nine service users may be aged between 60 and 65 years of age. Accommodation for this service is restricted to the dedicated unit on the lower ground floor. The unit must have a team of staff specifically dedicated to it. Any individual service user’s stay within the unit should not be any longer than 6 weeks. 20th July 2005 3. 4. Date of last inspection Brief Description of the Service: Cranwood is a residential home registered to provide care and support to up to 38 older people. Owned and operated by the London Borough of Haringey, and located in a residential area of Muswell Hill in North London, the home is close to local shopping and transport facilities. Cranwood is split into four units Oakwood, Marreet, Rosebank and the ICB unit. The main aim of the home as set out in the statement of purpose is To work with older people and their relatives in order to give advice, care and support” The objectives of the home are to: 1. Provide a comfortable/enjoyable residential care home for all service users 2. Create an environment, which enables service users to retain their Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 5 individuality, independence, dignity and privacy, as set out in the Charter of Rights for service users. 3. Encourage service users to maintain their previous friendships, skills, hobbies and interests. 4. Allocate to each service user a key worker, who will have designated responsibility for helping with his/her personal requirements. 5. Provide activities and a lifestyle for all service users, which will operate within a risk assessment system. 6. Offer a service of the highest quality, in a non-discriminatory, equal opportunities environment. Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed over one day. The duration of the inspection was approximately five hours. The manager assisted the inspector throughout the inspection. The staff on duty were five carers in the morning and four carers in the afternoon, three domestics, a laundry person, a cook, a kitchen assistant, administrator and one activity co-ordinator. There were twenty-four service users in the home at the time of this inspection and two service users were in hospital. Recently the home went through a major refurbishment programme which at the time of this inspection was completed except for a few sagging areas, which is being addressed by the contractors. The home is now bright, warm and inviting and the service users’ whom the inspector spoke to expressed this. Prior to the inspection the manager notified the lead inspector that the works had been complete. At present the ICB unit, which is situated on the ground floor. Is housing eight service users from The Red House, another older people’s residential care home based in South Tottenham, whilst their home is undergoing major refurbishment. The refurbishment for the Red House will be completed by August 2006. The care staff and management team from the Red House is supporting the service users in the ICB unit, ensuring that their continuity of care is being fully met. This inspection involved sampling a number of care plans, records, a tour of the building, the inspector completing a fire risk assessment, speaking to service users and observing the interaction between staff and service users, which was friendly and positive. Feedback was given to the manager at the end of the inspection. The inspector found the manager and the rest of the staff very open and helpful throughout the inspection and would like to thank them for their time and patients. What the service does well: Service users have their needs assessed and their care plans reflect those needs. Personal care is provided in a way that respects the privacy and dignity of service users and the arrangements for the administration of medication and adult protection promote their safety. There are two activity co-ordinators who provide activities for service users on four days of the week. Practice in the home aims to give service users choice and to maximise their independence. Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 7 What has improved since the last inspection? What they could do better: This inspection has identified nine areas of improvement and four recommendations. While it’s evident that the staff are experienced and competent, the home has failed to ensure that service users needs are consistently being supported, recorded, reviewed, monitored and up-dated appropriately. It is therefore required that the registered person submits an action plan to the Commission for Social Care Inspection (CSCI), which describes how they will address these matters. The action plan must describe how the registered person: • ensures that daily logs are completed after each shift • that monthly summaries address all the areas of risks and goals set for individual, showing clearly whether or not a risks or goals have been achieved • ensures that risk assessments are to be updated accordingly when any changes occur, (For instance a fall) • that the specific service user’s who has an ‘Aggression Log, Verbal and Physical’ chart in place must have clear and precise guidelines for care staff to support the individual appropriately • update the medicines policy • ensures all care staff food hygiene training is updated • ensures all care staff employed from an agency to handle and prepare food in the home must have in place a current copy of their food hygiene certificate available prior to starting their employment • submits an application form to the Commission with regards to registering the current manager for Cranwood • ensures all care staff undertake challenging behaviour training • to complete an environmental risk assessment that includes a fire risk assessment which is reviewed annually or when any changes occur. Reccomendations addressed in this report are deemed good practice. Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Service users are assured that their assessed needs will be met by the home. Therefore receiving appropriate care to meet individual’s needs. EVIDENCE: All service users have their needs assessed prior to admission, and copies of these assessments were seen on the four service user files examined during this inspection. The intermediate care (IBC) unit is currently housing the service users from another home within the organisation. A separate staff team is supporting the service users ensuring that their continuity of care is being appropriately met. A part of the inspection process was to inspect this unit separately. This was completed under the named home’s inspection report. At the previous inspection it was required that the registered person works with the equipment suppliers to resolve delays in the provision of adaptations to the homes of service users from the intermediate care unit. The manager stated to the inspector that she has spoken to the suppliers and the equipment is now in place. Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 11 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 Service users health, personal and social care needs are protected by the information recorded and motorised by the home on a monthly basis. However, this is not always consistent, potentially leaving service users at risk from harm. Therefore regular monitoring and reviewing will ensure that service users needs are met appropriately by the home. The medication at this home is well-managed prompting good health, however, the policy and procedures in place new to be reviewed and updated to ensure this practice remains. EVIDENCE: Service user plans seen during this inspection contained information on individual health, personal and social care needs, and there are targets set in order to meet these needs. There are records that indicate service users have access to health care services as required. Four care plans sampled evident that each service users has a named key worker recorded. Daily records, monthly summaries and risk assessments were in place. One of the care plans examined, regarding a specific service user whose care needs were complex. Had an in place a comprehensive and Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 12 detailed account of the specific service user’s care and how this is supported and managed by the home. This was deemed as a good example by the inspector. However, on the two other care plans examined the daily progress records had a number of omissions found. The manager explained that some of the omissions found related to weekend days that were duplicated on the form and these were not completed. However, other omissions found were not explained. It was advised that daily progress records must be completed daily, monitored and reviewed by the manager. Monthly summaries examined, however, the information recorded was brief and did not always address individual’s risks, goals, change in needs (such as a recent Fall) and outcomes. Nor did the monthly summaries reflect individual’s current objectives for health and personal care. Two service users ‘Aggression log, verbal and physical’ charts in place were half completed and did not have in place: • clear guidance for care staff on how to manage the individual’s behaviour that may at times become challenging • no date or when format is reviewed or monitored and by whom • what were the individual’s triggers points • and what are the different calming or relaxing technique care staff could use It is advised that all the care staff must undertake challenging behaviour training. To ensure that care staff are equipped to support individual service users appropriately who may have behavioural challenges. At the previous inspection it was recommended that care staff receive training in recording and that this focus on a record of the extent to which service users care plans have been met. At the time of this inspection two service users were admitted into hospital. Copies of Regulation 37 reports have been submitted to the Commission. One of the assistant managers showed and when through medication procedures with the inspector. It was evident that the medication is stored appropriately in a locked cupboard; only the assistant manager’s administers the medication to all the service users in the three units and all assistant managers are trained to administer medication. It was also evident that the assistant manager was knowledgeable about the home’s procedures to follow with regards to medication. However, the medication policy in place was last reviewed in 1999. It was advised that the medication policy must be reviewed. Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 13 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 & 15 Service users benefit from a good entertainment and social life within the home. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. However, service users are not confident that the staff employed to prepare and handled food have had their training updated regularly. Therefore potentially placing service user at risk. EVIDENCE: Standards 13 & 14 were assessed at the previous inspection and met. Therefore these Standards were not assessed at this inspection. The home employs two part time activities co-ordinators to provide activities in the home four days a week (Monday, Tuesday, Thursday, Saturday). During the inspection a number of service users were participating in a groups activity in one of the units lounge/dining areas. It was observed by the inspector that individual service users were enjoying the activity through their participation and the facial expression. Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 14 The menu plan shown indicated that the meals provided for the home is wholesome appealing and balanced. The lounges/dining areas are bright and pleasant. Part of the tour of the home was to inspect the kitchen area. The inspector was given protective clothing prior to entering into the kitchen. It was evident that the kitchen had been refurnished to a high standard. The cook gave the inspector a brief tour of the kitchen, informing the inspector of the menu choice for the day. The cook stated they had been in post for a number of years and the kitchen assistant was from an agency. On the notice board was displayed the cook’s food hygiene certificates, it was evident that this was out of date needed up dating. The kitchen assistant stated that he had completed his food hygiene training recently with the agency. It was advised by the inspector that the cook or any other staff member must have in place up to date food hygiene certificates. Any staff employed by through an agency to handle or prepare food must have a current food hygiene certificate available at the point of employment. Evidence of which must be on file. Cranwood DS0000033341.V286497.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): No Judgement made EVIDENCE: Standards 22 & 23 were assessed at the previous inspection and met. Therefore these Standards were not assessed at this inspection. Cranwood DS0000033341.V286497.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, 23 & 26 Recent investment has significantly improved the appearance of this home creating a comfortable and safe environment for those service users living and visiting Cranwood. EVIDENCE: Since the previous inspection the home has been through a major refurbishment. It was evident at this inspection that the home is clean, warm bright and inviting. Each unit is defined and has it own identity within a large establishment. Each unit has a number of single bedrooms; the communal areas are a kitchenette, lounge/dining area, bathrooms and separate toilets. The manager notified the lead inspector prior to the inspection that the works were now completed. However, there are a number of areas that still needs addressing by the contractors, which will be completed soon. All the bedrooms examined are individualised to meet the service users personality and taste. The bedrooms have all the amenities as required in the Standard 23 of Care Homes for Older People NMS. Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 17 The home is a large home with a number of quiet areas for individual to relax from at their own leisure. The inspector observed this on the day. Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 18 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 Service users benefit from sufficient staff on duty and are protected by the homes recruitment policies and procedures. EVIDENCE: The home recruits and selects staff in accordance with the London Borough of Haringey policies and procedures. These procedures based on principles of equal opportunity ensure that nobody begins work without appropriate references and the satisfactory completion of the appropriate checks. The rota was available and it was a clear reflection of the care staff present on the day on shift. Cranwood DS0000033341.V286497.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, 32, 35 & 38 The manager is supported well by the senior staff providing clear leadership throughout the home with staff demonstrating an awareness of their roles and responsibilities. Record keeping is good. Health and safety is maintained and in good order. However, the manager needs to produce a comprehensive annual environmental and fire assessment to ensure the home maintains a safe environment for the service users and staff EVIDENCE: The manager has been in post since September 2005. No application has been received by the Commission to register the manager, although the manager did stated that this was in hand. It was evident that the manager has good rapport with the staff team and the service users, this was observed by the Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 20 inspector during the tour of the home. The manager also stated that the team employed is hardworking and conscientious. Finance of service users money was discussed with the administrator. It was evident that clear accounting procedures were in place. It was evident that service users finances are managed appropriately by the home. Health and safety certificates were in place and in good order. Part of the inspection process included the inspector completing a fire risk assessment whilst touring the building. The purpose of the fire risk assessment was discussed with the manager. It was identified during the tour that all hallways and corridors were free from obstruction. The fire sign were not up at the time of this inspection, however, it was evident that all the fire signs were in the office waiting the contractor to complete this task. Fire doors were found to be in good order and those open had a magnetic device in place. Fire alarm testing is completed weekly, however, fire drills are not completed, quarter as required. This was discussed with the manager who did not at first understand the appropriateness of completing fire drills with service users who are older and at times may be confused. It was advised that all service users who are able to participate in a fire evacuation must take part in the home’s fire evacuation drills. Those service users who are unable to take part in a fire evacuation procedure must have on their individual care plan a detailed risk assessment of need with regards to fire evacuation. The risk assessment must include a section on how individual reacts when being supported, for example: - if an individual occasionally challenges or is confused or disoriented. This must be noted and updated accordingly. It was also advised that an environmental & fire risk assessment must be completed and reviewed yearly. The home’s record keeping is well maintained. All information held is easily accessible. All service users files gives clear comprehensive guidance to understanding individuals needs within the home. The service users care plans are very well maintained by the manager and care staff. However, it was the view of the inspector that there is still room for improvements. Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 21 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 3 X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X 3 X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X X 3 X X 2 Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 22 No 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 17 Requirement The registered person must ensure that daily logs are completed after each shift. This must be monitored and reviewed by the manager regularly. Evidence of this must be available for inspection. The registered person must ensure that the monthly summaries address all the areas of risks and goals set for individual, showing clearly whether or not a risk or a goal has been achieved. The registered person must ensure that risk assessments are to be updated accordingly when any changes occur. (For instance a fall). This is to be recorded in full with outcome and support needs and reviewed monthly. The plans must be signed and dated when completed. The registered person must ensure that the specific service user’s who has an ‘Aggression Log and Verbal and Physical’ chart in place must have clear and precise guidelines for care Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 23 Timescale for action 20/04/06 2. OP7 17 20/04/06 3. OP7 12(1) & 13(4)(b) 30/04/06 4. OP9 13(2) 5. OP15 18(1)(c) (i) staff to support the individual appropriately. The registered person must 30/04/06 update the medicines policy and include a section dealing with the possibility of disguising the medication, if non-administration will seriously endanger a service user’s health. The registered person must 30/04/06 ensure staff food hygiene training is updated. 6. OP31 7. OP38 The registered person must ensure all staff employed from an agency to handle and prepare food in the home must have in place a current copy of their food hygiene certificate available prior to starting their employment. Evidence of this must be recorded on file. 7&8 The registered person must 30/04/06 submit an application form to the CSCI with regards to registering the manager for Cranwood. 30/04/06 17(1a)Sch The registered persons must 4.17&13.4 ensure that fire drills are completed at least four times a year these are to be completed at different times of the day. A record of all fire drills undertaken must be maintained and reviewed accordingly. The registered person must ensure that those service users who are unable to participate in a fire evacuation procedure, a detailed risk assessment of needs with regards to how each individual is supported is clearly stated on their file. The information must include a section on weekly fire checks, fire evacuation procedure. This must be reviewed accordingly. Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 24 8. OP38 13(4) 9. OP7 18 The registered person must complete an environmental risk assessment that includes a fire risk assessment. This is to be reivewed annually or when any changes occur to ensure that the service users are safeguarded. The registered person must ensure all care staff undertake challenging behaviour training. 30/05/06 30/05/06 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. Refer to Standard OP3 Good Practice Recommendations It is recommended that the manager review the recording of the daily logs so that they evidence a link between targets on service users care plans and the work done with service users. It is recommended that staff receive training in recording and that this focus on a record of the extent to which service users care plans have been met. It is good practice to record all service users, staff and visitors whom participated in a fire evacution procedures. This would give a clear account of whom was present in the home at the time of evacution. It is also good practice to complete at least one of the fire evacuations during the night. It was reccomended that the care plan files should be indexed for easier access to information needed. 2. 3. OP3 OP38 4. OP7 Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Cranwood DS0000033341.V286497.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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