Inspection on 02/05/06 for Cravenside

This inspection was carried out on 2nd May 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cravenside 04/06/08

Cravenside 11/07/07

Cravenside 22/09/05

Cravenside 20/04/05

Cravenside 07/10/04

Cravenside 05/04/04

Cravenside 09/09/03

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

CARE HOMES FOR OLDER PEOPLE Cravenside Lower North Avenue Barnoldswick Lancashire BB18 6DP Lead Inspector Mrs Keren Nicholls Unannounced Inspection 2nd May 2006 9:30 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 Cravenside DS0000035008.V293658.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. Cravenside DS0000035008.V293658.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cravenside Address Lower North Avenue Barnoldswick Lancashire BB18 6DP 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) 01282 816790 01282 853620 JulieBurns@careservices.lancscc.gov.uk Lancashire County Care Services Mrs Julie Ann Burns Care Home 44 Category(ies) of Dementia - over 65 years of age (15), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2), Old age, not falling within any other category (21), Physical disability (6), Physical disability over 65 years of age (6) Cravenside DS0000035008.V293658.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. The service should at all times employ a suitably qualified manager who is registered with the Commission for Social Care Inspection Within the overall total of 44, a maximum of 20 service users requiring personal care who fall into the category of OP (either sex). Within the overall total of 44, a maximum of 15 service users requiring personal care who fall into the category of DE(E) (either sex). Within the overall total of 44, a maximum of 2 (named) service users requiring personal care who fall into the category of MD(E) (female) Within the overall total of 44, a maximum of 6 service users requiring personal care who fall into the category of PD(E) for intermediate care only (either sex). Within the overall total of 44, a maximum of 6 service users requiring personal care who fall into the category of PD for intermediate care only (either sex). 22nd September 2005 Date of last inspection Brief Description of the Service: Cravenside provides 24-hour accommodation and care to older people; older people who also have a dementia; people needing rehabilitation care and day care. The home is owned and managed by Lancashire County Care Services, which is a Lancashire County Council direct services organisation. The fee range is £299.00 - £388.00 per week (May 2006). Additional charges are made for hairdressing; chiropody; toiletries; newspapers and outings. The home has a booklet about ‘service details’ to give to prospective residents and displays a copy of the most recent CSCI inspection report by the front door. Cravenside is located near to Barnoldswick town centre, with footpath access to the town centre shops and other amenities. The home looks out onto a green and has an enclosed protected garden at the front. There are sitting areas and a car park by the front entrance. The premises are purpose-built, comprising three ground and three first floor residential units (each accommodating between 6 to 8 people) and a first floor day care lounge/hairdressing salon. There is a passenger lift. Each Unit has single bedrooms, a bathroom, toilets and communal lounge/dining area with integral kitchen (for light meals and snacks). The home has separate smoking rooms on both floors. The main kitchen and pay telephone are located on the ground floor. The home provides limited car and mini-bus transport (booked in advance). Cravenside DS0000035008.V293658.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit took place over 2 days. A total of 14.15 hours were spent at the home, when the inspector talked to the residents, a relative, staff on duty, the manager and area manager. She also looked at records and care plans; observed care practice; staff interactions with residents who had communication difficulties and toured the home. Consideration was given to written information provided by the manager prior to the site visit. All key National Minimum Standards were assessed. What the service does well: What has improved since the last inspection? The training programme had progressed, with staff attending courses to ensure the health and safety of residents (such as medicines safety and protection of older people); and to enhance the quality of life for residents (such as dementia care training). To protect the safety of everyone at the home, regular fire drills had been held. Cravenside DS0000035008.V293658.R01.S.doc Version 5.1 Page 6 Residents’ meetings were held to discuss issues such as meals, activities and problems. Also, everyone had been asked for their views and opinions on a ‘customer satisfaction’ questionnaire, so the home could plan improvements. A new staff member, to help out with office administration had been employed. This meant that managers could spend more time planning and improving care for residents. 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. Cravenside DS0000035008.V293658.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 Cravenside DS0000035008.V293658.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): 1,2 3, 4, 5 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service: Residents and their representatives were consulted about needs and wishes prior to admission. Trained people had assessed these needs, to ensure that they could be met by the home. However, not every resident had been given information about the home (to enable them to make an informed decision about whether Cravenside was the right place for them to live), in a format they could understand. Residents were sometimes accommodated in the intermediate treatment unit without a rehabilitation assessment, so it was not clear how their needs could be met. EVIDENCE: A file by the front door provided information about the home. Information booklets (including the complaints procedure) were displayed on notice boards in Units. Written information was not available for people using the rehabilitation service. Although large print is available, one resident said she Cravenside DS0000035008.V293658.R01.S.doc Version 5.1 Page 9 could not read the details she had been given, as the print was too small and two residents with a cognitive impairment said they found the information difficult to understand. Residents said that they knew what the home had to offer and several people said they or their relatives had visited Cravenside prior to their admission. Residents spoken with thought the home and the staff generally met their needs for accommodation, health, social and personal care. Pre-admission assessments had been conducted by social workers and these had been discussed with the manager of the home. The home had also completed a needs assessment (customer enquiry form) with some, but not all prospective residents, to ensure the home and staff had the necessary skills to meet needs. Files showed that residents had signed contracts. The manager was advised to confirm in writing to prospective residents whether or not the home could meet their needs. This is important as the manager explained there were occasions when residents who had not had a rehabilitation assessment or rehabilitation needs were admitted to the intermediate treatment unit. Additionally the home cannot at present meet the needs of people with dementia who need assisted bathing. Care plans were usually drawn up from needs assessments, but one person had no plan (see Health and Personal Care Section). Residents and a relative were very happy with the rehabilitation unit and said they had good support from trained and competent staff, Occupational Therapists and Physiotherapists. One person commented; “all the staff speak to me properly and explain things when I want them to”. Cravenside DS0000035008.V293658.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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service: Residents’ care plans did not make clear how assessed needs should be met. Shortfalls were identified in medication practices, which had the potential to place service users at risk and physical barriers compromised residents’ privacy and dignity. EVIDENCE: Four people’s care plans examined did not set out clear information on how residents’ needs should be met. One person’s care plan was missing. One person’s plan had not been started for some months following admission. There was no mention of planning to meet mental health or dementia care needs for two residents. One person’s plan had no management strategy for identified risks. Not all plans were reviewed monthly, according to the home’s procedure. Two residents described significant problems, which were not mentioned in their plans and staff queried whether the mobility needs of one person were being adequately met. Cravenside DS0000035008.V293658.R01.S.doc Version 5.1 Page 11 Each resident had a keyworker and residents said they were very happy with the care service they received from staff. Discussion with staff and residents suggested that that most needs were being addressed, even with lack of clear plans and guidance. However, this informal approach meant that continuity of meeting residents’ needs and wishes is dependent on staff memory and good verbal communication systems, which has the potential to place residents at risk of needs not being properly met and of care being reactive, rather than proactively planned. Daily records described the health and personal care provided and residents confirmed they had access to the GP of their choice, dental and chiropody treatment and attention from the district nurse. Incidents of pressure sores were monitored and appropriate advice taken. Weight was monitored, although there was little evidence of nutritional planning for weight gain/loss or maintenance in care plans. Medicines storage was appropriate and clean. Staff administering medicines had been properly trained and the home had good medicines procedures. However procedures were not always followed, which had the potential to place residents at risk of harm: There were several gaps in the administration record, so it was not clear whether residents had received their medicine at the correct time or at all; the signatures on the administration record did not match the signature sheet; there were no protocols to explain the reasons for all ‘as necessary’ medicines; and although only for a short time, medicines were left unattended. Residents were very happy with staff attention, describing staff as “wonderful” and “will do anything for you”. The staff team were committed to providing the best service they could and treated and spoke to residents with respect. Residents confirmed that personal care was conducted in private. Several residents were keen to explain how difficult life had become for them with the closure of heavy fire doors and five residents had made formal complaints. Residents said that they could not independently access bedrooms and toilets and had to wait for staff assistance, which was adversely affecting their privacy and dignity. An additional concern affecting dignity was with the laundry service: A formal complaint, a relative’s concern and discussion with staff and residents confirmed that clothing was still going missing, was spoilt, or sometimes residents were given another person’s clothing. Cravenside DS0000035008.V293658.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service: Routines were flexible, but physical barriers and problems with fire sensors restricted residents’ choices and control over their lives. Social activities were individually appropriate for the people who lived at Cravenside, providing daily variety and interest. Staff enabled residents’ contact with family and the local community. Residents enjoyed choices of nutritious and varied meals. EVIDENCE: Residents appreciated the day care activities on offer every day to suit different tastes and abilities and said they enjoyed singing, quizzes and ‘keepfit’ classes. Staff on the dementia care units continued to arrange video afternoons, ‘pamper days’ and baking. Residents said they liked reading and had books and newspapers. An Easter bonnet competition and singer entertainment had been held and residents enjoyed ice creams and sitting out in the sun on the afternoon of the second site visit. Several people said they liked to go out with family, friends or staff on outings. Activities for people who preferred not to go to the day care room were more limited and one person remarked she was “sometimes bored as there’s not a Cravenside DS0000035008.V293658.R01.S.doc Version 5.1 Page 13 lot to do”. Another resident explained she would be happy to do “little jobs” as she had at a previous home. The programme of outings had lapsed, staff explaining they had insufficient time and finances so far this year. Residents from the rehabilitation unit suggested an improvement would be to know in advance when special entertainment was booked in the day care room. Residents said their relatives were made welcome at any time and offered refreshment. They could receive visitors in the privacy of their own room. Clergy of various denominations visited the home to hold services and see individual service users. Policies and procedures promoted residents’ choice and independence. Residents said that they made lifestyle choices such as when to get up/go to bed, preferred time to bathe and how to occupy their time. A major source of concern for residents was the heavy fire doors, which the majority could not manage unaided and restricted their choice of moving freely and independently around home and going outside. The management had been discussing alternative arrangements, but no action had been taken. In addition, although management were arranging to reduce the sensitivity of fire sensors, concerns were expressed to the inspector regarding restrictions on residents’ choices of talc, perfume, deodorant, and other sprays. The lunch meal observed was nicely presented and well cooked, with choice of two dishes or alternative. Staff created a relaxed atmosphere with soft music and attention was given to independence by providing contrasting tablecloths and crockery. Residents’ comments included “the meals are 100 ”, “it’s a five star service” and “I really enjoyed my dinner”. Staff on the dementia unit said they would like to improve the service by displaying a daily menu. Menus, provided by the trained and experienced cook staff, were balanced and catered for health needs (such as diabetic and soft diets) and residents’ preferences. Residents could choose to have meals in their bedrooms. The Unit kitchens provided facilities for people to make their own drinks and snacks. A problem with timing between breakfast and lunch was being addressed by the manager and cooks. Cravenside DS0000035008.V293658.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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service: Complaints were taken seriously and properly investigated. Cravenside had a robust complaints procedure, but this was not always followed, which restricted complainant’s choices of taking matters further if they wished to do so. An appropriate vulnerable adults procedure and staff training ensured that people living in the home were properly protected from risk of harm. EVIDENCE: Residents understood, and had used the complaints procedure. Staff supported residents who complained. Two people commented that they thought their concerns were taken seriously and one person said he had recently talked to the manager about some problems, which had been resolved to his satisfaction. Evidence from the pre-inspection questionnaire stated there had been 8 complaints in the last 12 months. Records at the home showed that 6 complaints had been counted as one, as they concerned the same matter. Complaints were recorded, but the home’s procedure was not always followed in that: Written responses to written complaints were not made; some complaints were not dated, therefore a response within stated timescales could not be ascertained; and outcomes were not always recorded. Because of lack of formal response about an outcome, there was uncertainty for complainants about how to take matters further if they chose to do so. Several residents Cravenside DS0000035008.V293658.R01.S.doc Version 5.1 Page 15 said they were concerned about the fire doors, but “nothing had been done”. Complaints regarding the laundry service had not been resolved. Residents said they felt safe from abuse at the home. There were good adult protection procedures. Staff were knowledgeable about how to prevent abuse, how to protect residents and how to respond to suspicion or evidence of abuse. Cravenside DS0000035008.V293658.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, 21, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service: The home had an excellent standard of cleanliness. The building and grounds were maintained in good order, providing a comfortable and ‘homely’ environment. However, matters were identified as not providing safe surroundings in which to live or appropriate for personal care needs. EVIDENCE: The home was well maintained, with appropriate aids, adaptations and equipment to promote independence. Several residents said they liked the home very much and it was “always clean”. One person said she liked everything being on the same level … “there’s no stairs and everything’s handy”. The home was warm and bright; the décor, furnishings and majority of furniture were domestic in character, conveying a ‘homely’ feel. Private rooms were inspected with the permission of the occupant: Bedrooms were clean, comfortably furnished, nicely decorated and carpeted and Cravenside DS0000035008.V293658.R01.S.doc Version 5.1 Page 17 personalised with the personal possessions. Each reflected the occupant’s interests and personality and had lockable storage. Residents said they were very happy with and comfortable in their bedrooms, which they used at any time they wished and could keep secure and private with a door lock. No progress had been made to alter the bathrooms on the dementia care units. Bathrooms were too small to accommodate people who needed to use a wheelchair or to have staff assistance. Consequently, some residents were denied the opportunity and choice of having a bath, although their personal hygiene needs were met through ‘bed baths’ or (with staff availability) going upstairs to another Unit. Residents said they did not feel safe going through doors. They thought them hazardous and one person described how she had hurt her knee. Unsafe practice was observed when negotiating doors, especially people using mobility aids. Cleaning of walls, ceilings, fly screens and cooker hoods was not carried out, so compromising kitchen cleanliness. Cravenside DS0000035008.V293658.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, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service: Cravenside had a committed and stable staff team, who were trained and qualified. Levels of need and the layout of the home need to be considered when setting staff levels, to ensure resident’s needs are met. A robust and thorough staff recruitment process helped to ensure residents were cared for by staff who had been properly vetted. EVIDENCE: Residents had good relationships with the staff team and were keen to say that they were “grand lasses”, who were “wonderful”. Residents told of many small kindnesses of individual staff, which made them feel cared-for and special. Residents were very satisfied with the standard of care, several commenting that care “could not be faulted”. New rotas had started since the last inspection, with a shift change at 3:30pm. Staff and residents explained that routines and practices concerning afternoon activities had not yet settled. Staff were concerned they had insufficient time to talk to residents, as they were busy attending to domestic tasks and personal care needs. Although one staff member was allocated to each unit, several residents needed the attention of two staff, which necessitated calling staff from another unit: During the site visit, one resident had to wait a short Cravenside DS0000035008.V293658.R01.S.doc Version 5.1 Page 19 while for attention from two staff, causing him distress. Staff also noted the problems of working in isolation. According to information provided by the manager and training records, 60 of the care staff had achieved NVQ level 2 and several had achieved NVQ level 3, so exceeding this standard. Staff spoken to were enthusiastic about training, one person paying for her own course. The home had a training matrix showing completed basic training (including moving and handling, medicines awareness, health & safety, basic food hygiene, first aid, adult protection, challenging behaviour and dementia care). Records of induction training were not available and it was not clear whether casual staff received induction training to National Training Organisation targets (so staff have the knowledge and skills to meet the changing needs of residents). Training was not linked to care plans, which meant that potential improvement in the quality of life for individuals was not always addressed. The home had a robust recruitment procedure, which records and discussion with staff showed was followed satisfactorily. Cravenside DS0000035008.V293658.R01.S.doc Version 5.1 Page 20 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service: The manager provided leadership and management that promoted wellbeing. Adequate communication and quality assurance systems helped to ensure the home was run in residents’ best interests. Sound policies, procedures and staff training protected residents’ financial interests and health and safety, but risk was not always managed in a way that kept residents safe. EVIDENCE: An experienced and qualified manager, whom residents, staff and relatives considered approachable, ran Cravenside with the support of a management team and external managers. She had been unable to complete dementia care training as planned, but intended to update her knowledge and skills in this area in order to implement current best dementia care practice. Cravenside DS0000035008.V293658.R01.S.doc Version 5.1 Page 21 The home had various strategies to communicate with residents and other stakeholders, such as regular meetings, one-to-one discussion, care plan assessment meetings and annual customer satisfaction questionnaires. A new administrator (who was awaiting a job description) had been appointed, which gave the management team more time to improve the home. Residents said that staff listened to what they had to say and tried to make things better. One resident explained that he had recently had a long talk with the manager about his problems, and everything had improved. A residents’ meeting, where views and opinions about the food, activities and other issues were discussed and passed on to the management team for action, had recently been held on one Unit. The manager operated an ‘open door’ policy and throughout the inspection days, the views of residents, relatives, visitors and professionals were welcomed. Some residents identified problems and things they would like to do, which were not linked to their care plans, and for others each day followed much the same routine with no future plans. This had the potential for not meeting ongoing development for each person. The home had sound accounting and financial procedures and up to date insurances. Proper records and receipts were kept; residents said they were helped to manage their own money and had no concerns regarding the management of personal finances. However, the manager must ensure that the register of items in safekeeping for residents is correct and up to date. Current business and financial plans were not available for inspection, so residents could not be sure that Cravenside is able to meet the commitments specified in the home’s Statement of Purpose. The staff supervision programme was variable: Keyworkers and the management team thought this could be improved, to ensure residents have the best possible service from well supported and supervised staff. Some records had not been used in accordance with requirements (such as letting CSCI know when certain events had happened at the home) and one resident did not know that residents could look at their records if they wanted to. Generally, health and safety arrangements to protect residents were good, with several staff having attended safe working practice and infection control training. Safety checks on items seen at the home (such as fire extinguishers) were current and the manager provided information to confirm other checks (such as gas and electricity, fire drills etc.) were up to date. Accidents were recorded and risk assessments carried out. However, records showed that minimising the risk of fire (by keeping fire doors shut) resulted in injury to three residents as well as compromising their wellbeing. The manager must ensure that these risks are minimised. Cravenside DS0000035008.V293658.R01.S.doc Version 5.1 Page 22 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 3 2 2 3 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 2 X X 3 X 2 STAFFING Standard No Score 27 2 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 2 2 2 Cravenside DS0000035008.V293658.R01.S.doc Version 5.1 Page 23 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 OP1 Regulation 5(2) Requirement The manager must give a copy of the ‘service users guide’ to every resident (including those using the rehabilitation unit). (Timescale of 22/9/05 not met) Following a detailed health and welfare needs assessment, the manager must write to prospective residents to confirm whether or not his or her needs can be met by the home. (Timescale of 22/9/05 not met) The manager must prepare a plan of care (preferably with each person), make the plan available to each resident and keep the plan under review The manager must only admit people within the conditions of registration (i.e. Condition numbers 5 and 6: Within the overall total of 44, a maximum of 6 service users requiring personal care who fall into the categories of PD or PD(E) for intermediate care only). All staff must adhere to policies and procedures for safely administering medicines. In DS0000035008.V293658.R01.S.doc Timescale for action 04/05/06 2. OP3 14(1)(d) 04/05/06 3. OP3 15(1)(2) 31/07/06 4. OP6 S.24 Care Standards Act (2000) 04/05/06 5. OP9 13(2) 04/05/06 Cravenside Version 5.1 Page 24 6. OP10 12(3)(4) (a) particular, medicines must not be left unattended and Medicines Administration Charts (MAR) must be completed. The manager must ensure that 30/06/06 residents’ privacy and dignity is respected, in that physical barriers (heavy doors) are not obstacles to accessing toilets and bedrooms independently when they wish to do so. Residents’ dignity must also be respected when planning the laundry service (for example by not losing or being given other people’s clothing) Within 28 days (or sooner if appropriate), the manager must inform complainants of the action (if any) that is to be taken The registered persons must make sure that the hazards and risks to resident’s health and safety regarding negotiating fire doors are minimised. Appropriate bathing facilities must be provided in the two dementia care Units (timescales of 31/07/05 and 31/12/05 not met) The manager must inform the Commission of events such as deaths and events adversely affecting the wellbeing or safety of any resident. 7. OP16 22(4) 31/05/06 8. OP19 13(4)(a) (c) 30/06/06 9. OP21 23(j) 30/06/06 10. OP37 37(1)(2) 04/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cravenside DS0000035008.V293658.R01.S.doc Version 5.1 Page 25 1. OP1 2. OP7 3. 4. OP8 OP9 5. OP12 6. 7. OP14 OP16 8. 9. OP26 OP27 10. OP30 11. 12. OP31 OP33 The manager should provide a ‘service user’s guide’ in a format suitable for the individual (such as in large print, plain English or in formats suitable for people with a cognitive impairment etc.)(1.2) This recommendation carried forward from the last inspection in September 05: Care plans should set out in detail the action that needs to be taken to ensure that fully assessed needs of service users are met. The generalised goals in care plans should be specific and clearly identify how outcomes for service users are to be met, either by staff action or other means (7.2) and reviewed at least once a month (7.4) The manager should evidence how each person’s psychological health is monitored and what preventive and restorative action is provided (8.7) The manager should make sure that the criteria for PRN (as necessary) and variable dose medication is clearly defined and recorded (9.3) and signatures on the MAR charts match the signature sheet (9.3) The lapsed programmes of activities and outings for individuals and groups should be recorded (12.3) and up to date information about activities circulated to all residents (including rehabilitation unit) in suitable formats (12.4) Residents’ choices of perfume, sprays, talc and deodorants should not be limited (14.1) The manager should ensure the home’s complaints procedure is followed by dating complaints, responding to written complaints in writing and recording details of investigations and any action taken (16.3) The arrangements to ensure hygienic conditions in the kitchen (i.e. ‘high’ cleaning of walls, ceilings, fly screens and cooker hoods) should be carried out (26.1) The registered persons should take into account the layout of home, recent rota changes, laundry duties and the needs of some residents for assistance from 2 staff when planning for staffing numbers to meet residents’ needs (27.1) The manager should evidence what induction training (including for casual staff) has been carried out to ensure staff are initially competent to do their job (30.1) and ensure that foundation training is linked to residents’ assessment of need and care plans (30.3) The manager should update her dementia care training at an appropriate level in order to lead staff in best current practice (31.3) A commitment to life-long learning and development for DS0000035008.V293658.R01.S.doc Version 5.1 Page 26 Cravenside 13. OP34 14. 15. 16. OP35 OP36 OP38 each service user should be identified in his or her care plan (33.5). This recommendation carried forward from the last inspection in September 05: An up to date annually reviewed business and financial plan should be made available for inspection (34.5) The property register should be updated and property for people no longer resident returned (35.6) The manager should ensure all care staff receive formal supervision at least 6 times a year (36.2) The manager should ensure risks to safety to residents and staff from negotiating the fire doors are minimised (38.1) Cravenside DS0000035008.V293658.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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. 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