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Inspection on 10/01/07 for Craven Park Nursing Home

Also see our care home review for Craven Park Nursing Home for more information

This inspection was carried out on 10th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

The care home is located within a few minutes walk of the varied amenities and facilities of Harlesden, and has a very welcoming and warm atmosphere. The registered manager is experienced, competent, approachable, motivated, and keen to continue to develop the quality of the service. The care home employs an Activities Co-ordinator, who supports service users to have the opportunity to participate in numerous varied activities, including trips out in the community. The care home is very clean and warm. The care home has `homely` features, with furnishings of quality. Staff are very knowledgeable of the residents needs, and were observed to be sensitive and respectful to residents during the unannounced inspection.Staff receive varied and appropriate training and have the opportunity to gain qualifications in NVQ care courses. Care plans are comprehensive, accessible, and up to date, and regularly reviewed. Residents spoke of being happy living in the care home and confirmed that staff were generally caring and helpful.

What has improved since the last inspection?

The quality of the service remains good. Some redecoration of areas of the care home has taken place. The requirement from the previous inspection has been met.

What the care home could do better:

The care home needs to meet some requirements from this inspection. These include some maintenance issues, such as general repairs. Some procedures in regard to the management of service users monies need to be improved. Appropriate mechanisms need to be in place in regard to those doors in the care home that were observed to be wedged open during the inspection. There needs to be evidence of service users (or if applicable, significant other`s) agreement in regard to the use of bedrails. The `in house` protection of vulnerable adults procedure could be improved. There are also some recommendations resulting from this inspection that could be met.

CARE HOMES FOR OLDER PEOPLE Craven Park Nursing Home 1 Craven Road Craven Park Harlesden London NW10 8RR Lead Inspector Judith Brindle Key Unannounced Inspection 10th January 2007 08:45 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 Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Craven Park Nursing Home Address 1 Craven Road Craven Park Harlesden London NW10 8RR 020 8961 5678 020 8961 9254 cravenpark@bmlhealthcare.co.uk 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) GSG Nursing Homes Limited BML Healthcare Limited Mrs Mary Ampah Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th October 2005 Brief Description of the Service: Craven Park Nursing Home is a care home providing nursing and personal care, and accommodation, for up to 26 older people. The registered providers of services at the home are GSG Nursing Homes Ltd (in respect of the building) and BML Healthcare, a national care organisation (in respect of the business of staffing and care). The registered responsible person is Mr Lambert, Director of BML Healthcare. The home has been operating since 1995. The home is located within a residential area of Harlesden, within the London Borough of Brent. It is a few minutes walk from local amenities and Harlesden tube station. Bus routes are around the corner from the home. The home has a private driveway. There is parking for several vehicles on the forecourt of the care home. The building has three floors. Access is by passenger lift or stairs. One of the homes bedrooms is a double room. All bedrooms are fully furnished. All but two have en-suite toilet facilities. The home has three communal bathrooms that all have adaptations. One such room has a walk-in shower area. There are a number of additional toilets. The home has a large dining room that is also used as a day room for a number of service users. There is a separate main lounge. The home has medium-sized, enclosed garden, which includes a patio. Prospective residents and others have access to information about the service provided by the care home. Details in regard to fees can be accessed from the care home. The range of fees is presently £585.28p -£625 per week. Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout the day in January 2007. The inspector was pleased to meet, and speak with several service users, and staff. The purpose of the inspection was to spend time with the service users to gain their views of the service, assess key standards, and to follow up and assess as to whether the requirement from the previous inspection had been met. The registered manager had supplied Pre inspection information and documentation in 2006, and a comment card was received by the Commission for Social Care Inspection. The inspection included a tour of the premises, and inspection of service user’s care plans, staff personnel records, medication storage and administration systems, meals and mealtimes, and inspection of a variety of other records. The inspector spent a significant part of the inspection talking with several service users, and observing interaction between residents and staff. The registered manager was present during most of the inspection. Staff kindly provided all the information, and documentation requested by the inspector during the inspection. 23 National Minimum Standards were assessed during the inspection. What the service does well: The care home is located within a few minutes walk of the varied amenities and facilities of Harlesden, and has a very welcoming and warm atmosphere. The registered manager is experienced, competent, approachable, motivated, and keen to continue to develop the quality of the service. The care home employs an Activities Co-ordinator, who supports service users to have the opportunity to participate in numerous varied activities, including trips out in the community. The care home is very clean and warm. The care home has ‘homely’ features, with furnishings of quality. Staff are very knowledgeable of the residents needs, and were observed to be sensitive and respectful to residents during the unannounced inspection. Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 6 Staff receive varied and appropriate training and have the opportunity to gain qualifications in NVQ care courses. Care plans are comprehensive, accessible, and up to date, and regularly reviewed. Residents spoke of being happy living in the care home and confirmed that staff were generally caring and helpful. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 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 Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1 and 3 (Standard 6 is not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have the information that they need to make an informed decision about where to live. Arrangements are in place to ensure that residents have their needs assessed prior to moving into the care home. EVIDENCE: Records confirmed that the care home has accessible information and documentation about the service provided by the care home. This includes a statement of purpose and service user guide. The registered manager reported that all prospective service users and/or their relatives/significant others are given a ‘welcome pack’ of documentation including leaflets about the service. Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 9 The care home has an admission policy/procedure. The manager spoke of the process of comprehensive assessment that all prospective service users receive prior to their admission, to ensure that the care home can meet their needs, and that relatives/significant others are involved in the process of assessment as and when needed. The manager generally carries out this assessment. The care plans inspected all included service users personal details, including preferred name, health, social and welfare needs including assessment of nursing needs. The manager confirmed that this process of assessment was on going, and is particularly significant during the service user’s ‘settling in’ period. Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 7,8,9 and 10 Arrangements are in place to ensure that resident’s health, social, and personal care needs are set out in an individual care plan. There could be further development in ensuring that service users consent is obtained in regard to the use of some equipment. Residents are treated with respect and their right to privacy upheld. Medication is stored and administered to residents safely. EVIDENCE: All service users have a care plan. Three care plans were inspected. The care plans included evidence that the registered person promotes and maintains service users’ health and ensures access to health care services to meet their assessed needs. Care plans included evidence of comprehensive assessment of residents’ individual needs, which included, a photograph of the resident, personal information, including some recorded preferences such as preferred Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 11 name. Other assessment information included social needs; communication needs, sensory needs, personal care needs, religious needs and pressures area needs. The care plans inspected recorded comprehensive staff guidance to meet these varied individual assessed needs such as personal care needs, mobility needs, diet/nutrition needs, continence and specialist medical needs. This guidance is regularly reviewed. There was recorded evidence that service users are involved (if able) in the development and review of their care plan. The care plans included risk assessment such as risk of falls, nutritional risk assessment, pressure area assessment, and in regard to the use of bedrails. Bedrail risk assessments were signed by the manager, but there needs to be evidence that the service users have (if able) and/or relatives/significant others have signed the bedrail risk assessment/consent records. The registered manager reported that staff receive six monthly training in regard to the prevention of pressure sores. Service users’ progress is documented. A comment care received by the Commission for Social Care Inspection from a visitor/relative confirmed that they were kept informed of important matters affecting their friend/relative. Service users who kindly spoke with the inspector confirmed that they had the opportunity to attend specialist healthcare appointments including hospital appointments, optician and chiropody services. A service user spoke to the inspector about wanting an eye care appointment. The registered manager confirmed during the inspection that she had attended to this request. All service users are registered with a GP. The registered manager confirmed that there is accessible equipment necessary for the promotion of tissue viability. The inspector was informed that the care home is in the process of ensuring that the beds in the care home are adjustable in regards to height, and that several beds had recently been replaced with new ones. It is recommended that all the service users beds can be height adjusted. The home has a medication policy/procedure. There is accessible staff guidance in regard to medication administration. Medication is stored securely. Staff and records informed the inspector that the nursing staff that administer medication have received a training session in advanced medication management. There were no gaps in recording in regard to the service users’ medication administration records that were inspected. Service users were observed to freely access their bedrooms and the communal areas. It was evident from observation that staff respected service users privacy and dignity during the inspection. The staff induction records Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 12 confirmed that the issues of confidentiality, respect and dignity are included in the staff induction programme. Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 12,13,14 and 15 Arrangements are in place to enable residents to participate in activities of their choice, and to maintain contact with family/significant others, as they wish. Meals are varied and wholesome, and pleasantly presented. EVIDENCE: The care home employs an Activities Coordinator. She was on duty during the inspection and kindly spoke of her role. She spoke of organising service user group activities as well as activities on a one to one basis. Activities include keep fit sessions, painting, board games, discussion of news items/current affairs, arts and crafts, reminiscence, quizzes, activities including ‘Family fellowship sessions, that meet service users religious needs, and music sessions. Trips into the community also take place. These include visits to local parks, shopping and theatre trips. A record of activities is displayed on a notice board and information in regards to news items are also displayed in the communal area of the care home. Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 14 Service users were observed to participate in a number of activities during the inspection, including an arts and crafts session. The Activity Co-ordinator was observed to participate in some activities on a one to one basis with several service users. The Activity Co-ordinator had a good understanding of individual service users needs including their preferences in regard to activities, and it was evident that she was competent and very motivated in regards to her job role and responsibilities. Service users who kindly spoke with the inspector were positive about the activities that were provided by the care home. A service user spoke of enjoying recent Christmas and New Year celebrations in the care home. She spoke of having choice as to whether to join in activities or not. The care home has ‘open’ visiting. A feedback comment card from a relative received by the Commission for Social Care Inspection confirmed that they felt welcomed by the care home, and that they were able to visit their relative/friend in private. Records confirmed that there were numerous visitors to the care home. Service users confirmed that they were able to bring personal possessions to the care home. The registered manager spoke of how service users were informed and consulted in regards to issues about the care home. It is recommended that service users have the opportunity to participate in regular resident meetings. The menu is varied and wholesome. It should be displayed and be in an accessible format for service users, and show evidence of having been recently reviewed. There was evidence of some meals being provided that meet cultural needs, but this could be further developed. Service users spoke of enjoying the meals provided during the inspection. A service user confirmed that she could choose what she wished to have for breakfast. The kitchen included a variety of fresh, frozen and dried foods. The cook spoke of using quality ingredients. Staff were observed to assist service users with their meals as and when needed. Choice was offered to service users during lunch. Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards 16 and 18 Arrangements are in place to ensure that complaints are dealt with promptly and effectively, and that residents are protected from abuse. The ‘in house’ protection of vulnerable adult procedures could be developed. EVIDENCE: The care home has a complaints policy/procedure. This information is included in the service user guide and statement of purpose documentation, which the manager reported was provided to service users and others during the admission process. It is also displayed within the communal area of the care home. A feedback comment card received by the Commission for Social Care Inspection (CSCI) from a visitor confirmed that they were aware of the complaints procedure. A service user spoke of talking to a relative or a particular staff member if they had a concern or a complaint. Records and communication from the care home with the CSCI confirmed that the complaints procedure is followed appropriately. Service users and visitors have the opportunity to document their comments and suggestions in a file located by the front door. The care home has a protection of vulnerable adults procedure. This includes appropriate procedures but it needs to be clear that allegations of abuse of Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 16 vulnerable adults must be reported to Social Services and the CSCI within 24 hours, and if the allegation may involve commitment of a crime, the police must be informed immediately, and that investigation (i.e. pressing the person for more details etc) should not take place until agreed generally in a multiagency strategy meeting. The care home has a copy of the Local Authority Protection of Vulnerable Adults multi-agency policy and procedures. Records and staff confirmed that staff had received protection of vulnerable adults training. Staff who spoke with the inspector had knowledge and understanding of how to respond if there is a suspicion or allegation of abuse. Records confirmed that abuse awareness is included in the staff induction programme. Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards 19,24 and 26 The location and layout of the care home is suited for it’s stated purpose, and is clean, but some maintenance issues need to be resolved. The home provides accommodation for each service user, which is furnished and equipped to provide comfort and privacy. EVIDENCE: The location and layout of the home is suitable for its stated purpose. It is located within a few minutes walk from local shops and other facilities. Bus and train public transport is accessible close to the home. The garden is enclosed, tidy and attractive, and has garden furniture. Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 18 The inspection included a tour of the care home. The registered manager informed the inspector that there was an on-going maintenance programme of the care home. A maintenance person is employed. There are areas of the care home that have been repainted since the last inspection, but some communal areas should be redecorated. These include areas on the 1st floor, 2nd floor and in the kitchen (particularly in the small staff changing area). The carpet on the 1st floor was stained and worn in areas and needs to be cleaned or replaced. There were also some stains on the dining room carpet. A crack in a wall in the communal area on the 2nd floor needs repair. A leak in the ceiling above the stairs near the office needs repair. A large crack in an outside wall needs repair. A resident kindly showed the inspector her room. She reported that she was happy with the room. Service users spoke of bringing personal items with them on their admission to the care home. The care home was clean, warm and free from offensive odours during the inspection. Laundry facilities are located away from food storage and food preparation areas. The home employs a laundry person, who was very knowledgeable about infection control procedures and of the importance of providing a good service to service users. He spoke of hand washing some particular items of clothing, which need particular care. The care home has a policy/procedure in regard to infection control. Protective clothing including gloves and aprons was accessible to staff. Records confirmed that staff receive infection control training. Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standard 27,28,29 and 30 Arrangements are in place to ensure that staffing numbers and skill mix meet the needs of the residents. There is evidence that robust recruitment and selection procedures are carried out at all times to ensure that residents are protected. Staff receive appropriate training to ensure that they have the skills and competency to meet the needs of residents. EVIDENCE: The staff rota was available for inspection. There were four care staff, one registered nurse and the registered manager (who is a registered nurse) on duty during the inspection. A feedback form from a visitor supplied to the CSCI recorded that in the visitor’s opinion there were not always sufficient staff on duty. The manager spoke of responding in regards to staffing numbers in accordance to the needs of the service users, so that at times it is arranged that there is another care staff on duty. The manager confirmed that staff numbers were also kept under review. This should continue. At night there are two care staff and one registered nurse on duty. The home also employs domestic staff, a maintenance person, administration staff and an activities co-ordinator. Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 20 There were judged to be sufficient staff on duty during the inspection. Call bells were generally answered promptly. A service user did not know if they had a key worker, and said that ‘it would be handy to have one’. The registered person should ensure that all service users know who their key worker is. The registered manager confirmed that most staff had now completed an NVQ care qualification. Staff who kindly spoke with the inspector confirmed that they had completed NVQ level 2 and/or 3 care qualifications since being employed by the care home. A staff member had completed an assessors Award. The manager confirmed that there was an ongoing process of staff completing and commencing NVQ care courses. She and another staff member spoke of how the NVQ care courses had developed and improved care staff skills. The care home has a recruitment and selection policy/procedure. Three staff personnel files were inspected. This documentation confirmed that required recruitment procedures including ensuring the new staff have received a satisfactory enhanced Criminal Records Bureau check were carried out by the care home. A staff training plan was available for inspection. Records and staff confirmed that staff receive varied and appropriate training in regards to their roles and responsibilities. This training includes completion of a comprehensive staff induction programme, and other training including moving and handling training, basic First Aid, health and safety training, and medication training. There is also specialist training for nursing staff including phlebotomy training, urinary catheter care, dementia care training, and diabetes training. Some staff induction records were not signed by the manager. Management staff should always sign staff induction programme records. A staff member spoke of having ‘lots of training’. Service users who kindly spoke with the inspector confirmed that staff were ‘caring’ and had a good understanding of service users needs. Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standard 31,33,35 and 38 The resident’s benefit from an experienced and competent management approach to the care home. Arrangements are in place to ensure that the service provided by the care home is monitored and improved as necessary to meet the aims and objectives of the home. There needs to be development in the procedures in regards to ensuring resident’s financial interests are safeguarded. Health, safety and welfare of residents and staff are promoted and protected, but there needs to be some development in some aspects of health and safety. Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager is a registered nurse and has achieved qualifications in the Care of the elderly, and Mentoring in the Workplace. She also has a Diploma in Social Studies and an honours degree in Social Anthropology. She has also completed the Registered Manager’s Award level 4. She is presently completing an Internal Verification training course. It was evident during the inspection and from on-going communication with the CSCI that the manager is very experienced, competent and motivated. Service users who kindly spoke with the inspector were aware of who the manager was, and it was clear that there are clear lines of accountability within the home and with external management. Staff spoke of the manager as being approachable. The registered manager completed a ‘round’ of the care home, which included speaking to service users and staff, when she came on duty. She spoke of the importance of this duty. The registered manager informed the inspector that there is an Annual Review of the service carried out by the manager. Records confirmed that a Review had been completed in 2006. It was evident from inspection of records that documentation including care plans is regularly reviewed. The Senior Operations Manager of the Organisation carries out monthly reviews of the service. Service users ‘monies’ are generally managed by service users’ relatives/significant others, but there are some managed by the care home. Three service users financial records were inspected. Receipts of purchases were available for inspection. Cash balanced with the records of one service users monies, the balance of one was a few pence incorrect, and another did not balance with the record. The manager reported that money had been taken out for purchasing items for the service user. When money is taken out for service users purchases it must be clearly documented, and it is recommended that a petty cash slip be possibly used for recording this. Records indicated that service users ‘monies’ are not regularly audited/checked by staff. One service user’s money records and balance was ‘checked’ by staff twice in 2006, another, according to records had been audited once in 2006. There needs to be evidence that service users monies/accounts held by the care home are audited regularly, and that service users have individual assessment/risk assessment in regard to their ‘monies’ and the management of their finances. Up to date certificates of worthiness in regard to the servicing of electrical and gas systems within the home were available for inspection. Appropriate and required fire drills and fire system checks are carried out. Emergency fire action guidelines are displayed. Some doors in the care home were observed to be wedged open. Doors must not be propped or wedged Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 23 open. If doors are needed to be left open during the day, appropriate safe door opening mechanisms need to be in place. Advice needs to be sought from the Fire Service. Most doors in the communal areas of the care home have magnetic door closures. The care home has an up to date fire risk assessment. Health and safety checks including the servicing of manual handling equipment including hoists and after temperature checks are carried out. Staff spoke of some bathing hoists not being suitable for some service users (particularly those who are heavier/larger than others). The registered manager spoke of reviewing these hoists, and of the possibility of replacing them. This is recommended. The registered person needs to ensure that service users have their moving and handling assessment reviewed which includes assessment of the service users weight to ensure that the bathing hoist equipment is suitable for each service user. The inspector as informed that the care home has only six height adjustable beds, and that six more had been ordered. It is recommended that all the service users beds can be height adjusted, to reduce the risk of injury to staff and service users. Risk assessments in regard to safe working practices were available for inspection. Fridge/freezer temperatures are monitored. The certificate of employers liability insurance was up to date and displayed. Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 24 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 2 X X 2 Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 12,13(4) Requirement Timescale for action 01/05/07 2 OP18 13(6) 3 OP19 23(2) There needs to be evidence that the service users have (if able) and/or relatives/significant others have signed the bedrail risk assessment/consent records. There needs to be needs to be 01/04/07 clarity in the care home’s protection of vulnerable adults procedure: • that allegations of abuse of vulnerable adults must be reported to Social Services and the CSCI within 24 hours and if the allegation may involve a commitment of a crime, the police must be informed immediately, • and that generally investigation is not to take place until agreed in a multi- agency strategy meeting. • The carpet on the 1st floor 01/05/07 was stained and worn in areas and needs to be cleaned or replaced. • A crack in a wall in the communal area on the 2nd floor needs repair. • A leak in the ceiling above DS0000022925.V325193.R01.S.doc Version 5.2 Craven Park Nursing Home Page 26 4 OP35 12,13(4) (6) 5 OP38 13(4) 6 OP38 12,13(4) the stairs near the office needs repair. • A large crack in an outside wall needs repair. • When money is taken out 01/04/07 by staff for service users purchases it must be clearly documented. • There needs to be evidence that service users monies/accounts held by the care home are audited regularly • and that service users have individual assessment/risk assessment in regard to the management of their finances. • Doors must not be propped 01/04/07 or wedged open. If doors are needed to be left open during the day, appropriate safe door opening mechanisms need to be in place. • Advice needs to be sought from the Fire Service. The registered person needs to 01/04/07 ensure that service users have there moving and handling assessment reviewed, which includes assessment of the service users weight to ensure that the bathing hoist equipment is suitable for each service user. 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 Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 27 1 2 OP14 OP15 3 4 5 6 7 8 OP19 OP27 OP30 OP33 OP35 OP38 It is recommended that service users have the opportunity to participate in regular resident meetings. • It should be displayed and be in an accessible format for service users information, and show evidence of having been recently reviewed. • meals that meet cultural needs, could be further developed. Some areas of the care home should e redecorated. The registered person should ensure that all service users know who their key worker is. Management staff should always sign staff induction programme records. Service users should have the opportunity to participate in regular planned resident meetings. It is recommended that a petty cash slip be possibly used for recording when any service user’s money has been taken out by staff for purchasing items for service users. • Bathing hoist equipment should be reviewed and replaced if necessary. • It is recommended that all the service users beds can be height adjusted. Craven Park Nursing Home DS0000022925.V325193.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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