Inspection on 22/02/07 for Credenhill Court

This inspection was carried out on 22nd February 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.

Other inspections for this house

Credenhill Court 06/01/06

Credenhill Court 14/06/05

Credenhill Court 25/11/04

Credenhill Court 10/06/04

Credenhill Court 10/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Credenhill Court Credenhill Hereford Herefordshire HR4 7DL Lead Inspector Philippa Jarvis Key Unannounced Inspection 22nd February 2007 08.20 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 Credenhill Court DS0000024702.V324041.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. Credenhill Court DS0000024702.V324041.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Credenhill Court Address Credenhill Hereford Herefordshire HR4 7DL 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) 01432 760349 01432 760755 Mr Narendra Nauth Mrs Sheila May Nauth Mrs Susan Patricia Davies Care Home 35 Category(ies) of Dementia - over 65 years of age (35), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (35) Credenhill Court DS0000024702.V324041.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate service users over 60 providing there needs fall within the categories of registration. 6th January 2006 Date of last inspection Brief Description of the Service: Credenhill Court is registered primarily to provide accommodation and personal care for thirty five people over the age of 60 who need care due to their age or because they have care needs due to the effects of dementia related illnesses. There are also some people who have lived at the home for a while who are under 60 and have learning disabilities or mental health related needs. The home is no longer offering places to people under 60 or to people with learning disabilities. Credenhill Court is a large country house set in large grounds and has lovely rural views, especially from the rooms at the front of the house. Credenhill village church is reached from the same driveway and is just a few minutes walk from the Home. The village of Credenhill (with a post office and general stores) is about a mile away. Hereford city centre is 4 miles. The accommodation is on 3 floors with the majority of bedrooms being single. There are bathroom and toilet facilities on each floor and 2 sitting rooms and 2 dining rooms on the ground floor. Credenhill Court DS0000024702.V324041.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days. Time was spent talking with the manager and her deputy, staff members, relatives and residents. Time was also spent looking round the building and sitting with residents in the lounges observing life in the home. Because the majority of residents have dementia or mental health needs the extent to which their views could be sought directly was limited and some reliance had to be placed on observation to get an impression of what life at the home is like from their point of view. Comment cards were not received form the residents because the manager thought that they would not be able to complete them without staff assistance, which would affect the honesty of their content. The home sent comment cards to relatives, GP practices and health and social care professionals. A number of records and polices and procedures were also examined as part of the inspection. What the service does well: There is a friendly, welcoming atmosphere at the Home. The staff group is hardworking and conscientious and have a caring, respectful approach to residents. People are treated very much as individuals. Comments received form all sources were very positive. One social care professional said, “Staff are friendly and aware of residents needs.” A relative said, “Every time we visit the home we always get a warm welcome from any member of staff, which shows, to me at least, a good rapport and homely feeling among the residents.” Relatives all reported that they were welcome to visit at any time. The health care needs of the residents are met is given good attention and any concerns are referred promptly. The home deals with any matters that are raised appropriately and encourage relatives to let them know if they have any concerns. Relatives reported that any issues they raise are dealt with promptly and efficiently. The house is large with lots of space for those who like to walk about. Improvements to the accommodation are carried out regularly and overall the house is clean and comfortable. Routine maintenance is also carried out. The home is set in large attractive grounds and there are beautiful views over the surrounding countryside. Credenhill Court DS0000024702.V324041.R01.S.doc Version 5.2 Page 6 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. Credenhill Court DS0000024702.V324041.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 Credenhill Court DS0000024702.V324041.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): 1, 3 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information they need to choose a care home that will meet their needs. Their needs are assessed before they are admitted so that the home is certain that it can provide them with a suitable service. EVIDENCE: Prospective residents are strongly encouraged to spend time in the home, including an overnight stay, before coming to live there. This provides them with an opportunity to make an informed choice about admission and for the home to gain further information about their care needs. They are also provided with a personal copy of a Service User Guide that gives information Credenhill Court DS0000024702.V324041.R01.S.doc Version 5.2 Page 9 about what it is like to live in the home. There is a further copy available in the main entrance hall. When a prospective resident is referred to the Home by a social services department, the manager insists on receiving a copy of their assessment before considering the placement. The manager or deputy managers carry out their own assessment of a person’s needs whether they are funded by a placing authority or in a position to fund their care themselves. Admissions to the home only take place if the service is confident that staff have the skills, ability and capacity to meet the needs of the prospective service user. Credenhill Court DS0000024702.V324041.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): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents receive good support with their health, personal and social care needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The files for three residents were examined. Each one has a plan of care. This is written in plain language, is easy to understand and considers all the areas of the person’s life including health, personal and social care needs. The plan includes risk assessments where appropriate. The plans are reviewed each month by a member of care staff who has built up a special relationship with that person and is known as their key worker. Any changes to the care plan are recorded on the back of the form. Examples were found of plans where the changes were so significant that the whole plan needed to be rewritten. The home aims to involve the resident and their family in the preparation of the care plan and some had been signed by them to indicate their agreement Credenhill Court DS0000024702.V324041.R01.S.doc Version 5.2 Page 11 with the content. Whilst the care plans contain a lot of useful information, care needs to be taken to ensure that the assessment then describes how this should be translated into action. Service users have ready access to health and medical attention. The district nurse confirmed that the home refers service users who need health care attention appropriately and that they carry out all actions that she requests. There is also information on service user files about contact with other health care professionals and comment cards received from them indicate that they have confidence in the health care provided at the home. Examples were seen in the individual daily reports of healthcare issues being identified, recorded, reported and followed up. However examples were also seen where there was no report of their follow up. This is more likely to be a failure in recording than in action taken. There is evidence that where residents have individual health care needs that the staff have taken specialist training with regard to this. The home has a car and uses this to take residents to appointments in the community. The residents are all well presented and their dress reflected their personal choice. They can choose to have a bath or shower as often as they wish and are supported to be as independent in this area as they are able to be. Particular attention is given to ensuring that privacy and dignity are promoted when delivering personal care. Service users were observed to spend the day as they chose and to have full access throughout the home. All relatives who contributed to the inspection reflected their satisfaction with the care provided. Examples of comments made include: “All round I’m pleased. They have accepted her as an individual.” “…..is extremely well cared for in this home and I find the staff very caring and helpful.” Positive comments were also received from the health and social care professionals who returned a comment card: _ “I am very happy with the level of care and professionalism given to my clients at Credenhill Court. They provide an excellent service, and I wish we had more resources of the calibre of this home.” “My experience of working with Credenhill Court is very positive. They provide care which meets individual need; they work creatively and respond to residents wishes wherever possible. Their approach is respectful, caring and flexible.” The staff were observed to have a very caring approach to the residents and a number of kind and warm interactions were seen. Personal care needs are handled efficiently but without drawing attention to the action being taken thereby compromising the persons dignity. Credenhill Court DS0000024702.V324041.R01.S.doc Version 5.2 Page 12 The approach to the management of medication is generally good with care and attention being given to ensure that appropriate procedures are in place. A number of improvements in relation to medication practice have taken place. The home still needs to develop written guidelines for each service user who takes medication on an “as required” basis, to ensure staff have clear instructions about when it should be administered. Staff who are involved in handling medication have all received training to ensure that they have the right knowledge to carry out this task. Credenhill Court DS0000024702.V324041.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): 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. Residents are settled and well supported in the daily routine in the home. Further consideration should be given to meet individual lifestyle choices in this area of practice. EVIDENCE: Five residents were spoken with during the inspection and time was also spent observing the daily routine in the home. At the time of arrival on the first day many residents were already up. Staffing levels mean that there has to be an early start to the day to ensure that everyone is up and dressed by a reasonable time. The day starts at 6am but the manager expressed her confidence that no one had to get up unwillingly. People who are able to express a preference can request to get up at a later time. It is evident that people feel comfortable in the home and the spacious environment allows for those who like to walk around. Credenhill Court DS0000024702.V324041.R01.S.doc Version 5.2 Page 14 The care plans do not reflect how the home intends to meet the needs of each resident for activity and stimulation. Residents who are able are enabled to go out into the local community. The home arranges some activities for service users such as a visiting music man who provides entertainment and is much enjoyed by the residents. On the day of the inspection a beautician came to provide manicures for those who requested this. Staff are expected to spend time with the residents during the afternoons for activities and stimulation. Staff spoken with said that they did what they could but felt that they did not have sufficient time available to carry this out well. There is no evidence of recent trips out and one resident said that she would like to go out a little more. There are extensive, attractive gardens at Credenhill Court. Some residents are able to access these independently although there is no area for those with dementia illnesses to walk in without staff escort. One relative commented that his mother used to like her garden and he thought that she would like to be able to go out into the garden more often. Family and friends feel welcome and know that they can visit the home at any time. Staff make time to talk to visitors and share information with them appropriately. The residents spoken with all said that they enjoyed the meals that were provided. The cook is experienced in good home cooking and the main meal on the day of inspection looked healthy and appetising. The cook is familiar with the dietary requirements of the residents and she said that sometimes she talks with them about the menus. There is training booked for the week following the inspection with the community dietician on nutritional needs of older people. There is no routine choice of the main meal but residents said that they could request an alternative if they did not like what was provided. There is however a choice at breakfast and tea. There are two small dining rooms and the meals are provided in two sittings because there is insufficient space for all the service users to eat at the same time. One relative commented that the home had dealt well with the particular eating problems presented by his mother. Staff were observed to provide assistance for those who needed help with eating and to do this in a sensitive manner. Credenhill Court DS0000024702.V324041.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): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and others involved with the service have access to an effective complaints procedure. They feel protected from abuse within the home although staff need further training in this area to ensure they have full knowledge of appropriate procedures. EVIDENCE: There is a complaints procedure that is up to date and easy to understand. Relatives spoken with confirmed that they knew about this procedure. They also confirmed that they are able to raise issues with the staff or the manager and that these are dealt with promptly before they become a formal complaint. Staff spoken to knew that if they are approached about a complaint they could not deal themselves they should take details and pass the information on to the manager The home has a complaints log and this showed that there had been one complaint since the last inspection. The details in the log indicated that this had been taken seriously and appropriate action taken promptly. Staff are told about adult protection procedures at induction but no formal training has been carried out in this area of practice since this time. One member of staff spoken with was not aware of the correct course of action to take in the event of suspected abuse. Staff are, however, clear that they would not accept residents being harmed in any way. There is information Credenhill Court DS0000024702.V324041.R01.S.doc Version 5.2 Page 16 readily available in the office and also in the staff handbook. To make sure that all staff are familiar with what is expected of them it is strongly recommended that additional training is arranged and that the topic is covered at staff meetings and in individual staff supervision. Residents and all others associated with the home said that they are very satisfied with the service provision and that they feel safe and well supported by the staff and the management who have their protection and safety as a priority. Credenhill Court DS0000024702.V324041.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): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have rooms that met their needs and their bedrooms offer enough space for them to bring in personal possessions. The home is well furnished, equipped and maintained so that service users can enjoy their surroundings. EVIDENCE: The home has a well-maintained environment that provides aids and equipment to meet the care needs of the people who live there. There is a handyman employed to deal with the routine maintenance matters. It is a pleasant and safe place to live and residents are able to bring personal possessions into their rooms so that they can make them individual to suit their preference. A few bedrooms are small although most are adequately sized. Credenhill Court DS0000024702.V324041.R01.S.doc Version 5.2 Page 18 There are some shared rooms and screening has been provided to ensure the privacy and dignity of those who live in these rooms. The home is in the process of fitting ensuite facilities in some of the larger bedrooms. Consideration should be given as to whether these would be more suitable if they were fitted to the ceiling rather than cubicle style. There are large well-maintained gardens. Two wooden gazebos have been built at either side of the front lawn providing a pleasant shaded place to sit and look at the views. This positive addition to the garden could be of greater benefit if paths with handrails were created to help residents walk across to them. There are two lounges and two dining rooms. In addition some residents choose to sit in the spacious hall where they can watch people coming and going. The small dining room also doubles as a staff area when they have their breaks. At these times this room is not fully available for residents to use. There are no separate facilities for staff in the home. There is a choice of bathing facilities, both assisted and unassisted, with baths, showers and toilets strategically placed around the home. The home does not have a dedicated sluice provision. The home is well lit, clean and tidy. It smells fresh. Consideration is given to the prevention of infection. The laundry is suitably equipped although rather small for purpose. There are hand-washing facilities sited throughout the home and these are fitted with liquid soap and disposable hand towels to help prevent cross infection. The kitchen is not fitted with a dishwasher. The provision of this piece of equipment would further enhance infection control measures in the home. In a Home this size it would be reasonable to expect there to be a commercial size dishwasher in the kitchen. Credenhill Court DS0000024702.V324041.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): 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. Suitable staff are being employed to work with the residents. They receive training to help them understand the needs of the people living in the home. There are times of the day when the care staff are very busy. EVIDENCE: Staff seen during the inspection were tidy and smart. Their manner towards the residents was caring, respectful and efficient. They knew each person well and treated them as individuals. Copies of rotas were provided with the pre inspection information and these reflected the staffing arrangements at the time of the inspection. Some relatives made comments about the lack of staff available. A comment was also made by a GP about there often being a long delay in finding an appropriate member of staff to consult with. The inspector spent time in the communal areas and there were periods when no staff were around there for several minutes because they were dealing with the care needs of residents in another area of the house. The increase in the number of people at the home with dementia related care needs has had an impact due to the time needed to provide good person centred care. Staff felt that they have time to look after Credenhill Court DS0000024702.V324041.R01.S.doc Version 5.2 Page 20 the residents’ physical care but some did not think that they are able to spend enough time to talk to residents and to cater for their social needs. Having enough time to keep up to date with each person’s care plan was also proving to be difficult. Some staff spoken to said that they had not read all the care plans. Three staff files were examined. These confirmed that recruitment was satisfactory with appropriate checks and references being done to ensure that suitable people were employed to work with the vulnerable residents. Following appointment, new employees start a period of induction training. The file of a recently employed person was examined and although she had been working in the home for five months her induction was incomplete. The home uses an induction information book and an activity book but the manager was unsure whether these met the common induction standards set down by Skills for Care, the sector training organisation. The home provides a range of training for staff and the files examined showed that they had done a significant amount of relevant courses. There were some gaps in core training such as Adult Protection. Some staff had not completed required training updates even though the home had made this training available. The home provides training in aspects of care that are relevant to the care needs of their service user group such as dementia care and understanding mental health. The management of the home also encourage staff to take training in national vocational qualifications although only a few had actually achieved this award. The home has altered the system of record keeping for providing information about training completed and training needed for each staff member. The system in use currently is muddled and needs attention to provide explicit information. Credenhill Court DS0000024702.V324041.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): 31, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run to support and care for the residents by experienced and caring managers. They are open to constructive criticism and eager to continually improve their practice. They provide support to the staff but this needs to develop a professional formal approach. There is a sound approach to safe working practices in the home to help ensure the safety of the staff and residents. EVIDENCE: The manager has the required qualification and experience, having managed the home for almost fourteen years, and is competent to run the home. She is Credenhill Court DS0000024702.V324041.R01.S.doc Version 5.2 Page 22 supported by a deputy. They are focussed on the needs of the residents and lead and support a loyal staff team. Whilst they have access to a computer and other office equipment in nearby buildings they do not have this provision, to help with the smooth running of the office, available on site. The staff confirmed that the support they receive from their manager is good. The Manager is aware of the importance of individual staff supervision and in line with the Home’s stated policy is trying to get this underway but, with such a large staff team, finding it hard to fit this in with all the other demands on staff and management time. This was discussed and a steady, planned approach to this accepted as the most realistic way forward. This needs to involve senior staff and provision of training for them to be able to supervise staff rather than the manager and deputy trying to see everyone themselves. New forms are available to use when this aspect of practice is fully implemented. Whilst structured supervision arrangements are not well established, staff said that the manager and deputy willingly make themselves available to talk to staff who need to discuss work issues and any personal difficulties. The home provides a number of service users with support in managing their finances. There is a policy and procedure regarding this. The files for two service users were examined where there is such support and the information detailed and records kept were fully accountable. Health and safety of staff is covered in the Home’s written procedures including the Health and Safety policy and the grievance procedures. Health and safety related training is provided by external trainers and the cook has done a health and safety course. She has additional hours during which she does basic health and safety induction for new staff and annual refresher training for all staff. Responsibility for health and safety is undertaken by an additional staff member who has a HSE recognised Health and Safety qualification. The manager and her deputy do the moving and handling risk assessments but they have not had designated training in this area. Equipment is serviced as required and copies of servicing and maintenance records information requested were provided. Information in the fire log indicated that all fire safety checks and tests are carried out with appropriate frequency. Credenhill Court DS0000024702.V324041.R01.S.doc Version 5.2 Page 23 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 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 2 X 3 Credenhill Court DS0000024702.V324041.R01.S.doc Version 5.2 Page 24 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 13 Requirement The manager, deputy or a senior member of staff must do moving and handling training at a level that develops their knowledge and skills for carrying out moving and handling assessments and for monitoring moving and handling practice at the home. Previous timescale of 30/09/05 not met. Written information must be recorded for each resident describing the use of any medicine prescribed ‘as required’. Previous timescale of 15/12/05 not met. The home must provide sluicing facilities to allow equipment to be cleaned appropriately. Plans should be presented by the date stipulated. Previous timescale of 15/12/05 not met. Timescale for action 31/05/07 12. OP9 13(2), 17(1) 30/04/07 16. OP26 23 31/05/07 Credenhill Court DS0000024702.V324041.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations The registered person should consider obtaining information about residents preferred daily routine on admission the home so that they can ensure that the home is staffed to cope with periods of peak activity. The registered person should consider making an area of the garden secure for those who like to spend time outside to allow them the freedom to access the garden without an individual escort. It is strongly recommended that discussion about adult protection is regularly included on the agendas of staff meetings and individual supervision as well as in staff training to make sure that all staff are fully aware of the correct action to take if an adult protection issue arises. CARRIED FORWARD FROM LAST INSPECTION REPORT. Laying paths with handrails would improve access to the two new pagodas in the garden. CARRIED FORWARD FROM LAST INSPECTION REPORT. It is recommended that a dishwasher be provided in the kitchen. CARRIED FORWARD FROM LAST INSPECTION REPORT. Consideration should be given to providing a dedicated staff room. It is recommended that a small group of suitably experienced staff are identified to provide staff supervision to the wider team and that these staff are given the necessary training to equip them for this role. NOT CARRIED FORWARD FROM LAST INSPECTION REPORT. 2. OP12 3 OP18 4 OP19 5 OP19 6 7 OP19 OP36 Credenhill Court DS0000024702.V324041.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. Extracts may not be used or reproduced without the express permission of CSCI Credenhill Court DS0000024702.V324041.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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