Inspection on 07/10/08 for Croft House

This inspection was carried out on 7th October 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Croft House 03/10/07

Croft House 12/10/06

Croft House 21/11/05

Croft House 16/05/05

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Croft House 26 Kirkham Road Freckleton Preston Lancashire PR4 1HT     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Phil McConnell     Date: 0 7 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Croft House 26 Kirkham Road Freckleton Preston Lancashire PR4 1HT 01772633981 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Janet Margaret Finn Type of registration: Number of places registered: Ammram Limited care home 22 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 22 Date of last inspection Brief description of the care home Croft House Care home provides residential care for up to 22 older people. It is situated in the village of Freckleton, which is close to the city of Preston. Leisure amenities are close by as well as local shops and a public transport system. The home is on two floors and there is a chair lift in place. There are a number of aids and adaptations in place throughout the care home suitable for the age range and needs of the people living there. There are twenty single rooms and one double room, at Care Homes for Older People Page 4 of 30 Over 65 22 0 Brief description of the care home present only one bedroom has en suite facilities. The present rate of charging is between £375.55 and £413.00 per week. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: Information was gathered over a period of time in order to assess the key standards that are identified in the National Minimum Standards for care homes for older people. The information obtained included, the Annual Quality Assurance Assessment (AQAA), which is a self assessment document completed by the registered manager.It was suggested to the manager that future AQAA documents would benefit from more detailed information. An unannounced visit to the home was carried out on the 7th of October 2008. The registered manager was available throughout the day. Four service users files were examined including the most recent person to go and live at Croft House,with some discussions taking place with some of the service users throughout the day. There was also the opportunity to observe the interactions and Care Homes for Older People Page 6 of 30 relationships between the service users and the staff members on duty. Four staff files were also examined, including the recruitment procedures and training provided to staff.(See staffing section) There was the opportunity to have brief conversations with some of the staff and some visitors to the home. A full tour of the premises was carried out. (See environment section) The homes policies, procedures and all relevant documentation including health and safety inspection certificates were examined (See management section). What the care home does well: What has improved since the last inspection? What they could do better: The introduction and maintaining of appropriate, meaningful and stimulating activities should be provided on a daily basis within the home. The redecoration of the majority of the home is needed to ensure that people live and work in a pleasant and comfortable environment. Some areas of the home are in need of being properly and regularly cleaned (See environment section). The use of energy saving bulbs does not provide sufficient lighting. This could potentially increase the risk of falls, especially with people who have visibility problems. It was suggested to the manager that conventional bulbs should be used, in order to improve the lighting in the home and reduce the risk of falls. The conservatory / dining room is still very unsightly,with the roof potentially still being a safety hazard and health risk. The rusty/leaking cabinet freezer needs to be replaced, in order to also maintain health and safety. The windows are in need of having restrictors fitted, in order to prevent accidents and Care Homes for Older People Page 8 of 30 to deter any unlawful entry to the home. Some of the homes radiators are in need of either being covered or the radiator being removed, helping to prevent potential accidents. The manager was informed of the radiators in question and an asssurance was given that this issue would be addressed. (See Environment section) The recruitment police clearance checks need to be more robust. To help ensure that only suitable people are employed, to care for vulnerable people. The staff training needs to increase, because at the present time the training is very limited. This causes some concern especially with regards to the lack of safeguarding adults training. There is a need to inform the Commission if the registered manager is to be absent for more than 28 days. It is also necessary that the home is appropriately well managed on a day to day basis. There is a need to carry out monthly Regulation 26 visits, in order to monitor the progress of the environment and to monitor the wellbeing of the people who live at Croft House. Regulation 37 notifications must be consistently sent to the Commission. This is a legal requirement and is necessary for recording purposes. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 30 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a satisfactory pre-admission process in place, helping to give the assurance that prospective service users needs will be clearly identified and then determined if the persons needs can be provided for. Evidence: Four service users files were examined including the last person to go and live at Croft House. The files contained appropriate and relevant assessment information including,Social Services assessments, the homes own admission assessments,Social Services contracts and one person had a pre admission transfer document from another home.This demonstrated that relevant and appropriate information had been obtained, in order to gather as much information as possible. One relative said, She came in as an emergency and the social worker was involved in bringing mum into the home. We think its wonderful here. Care Homes for Older People Page 11 of 30 Evidence: The Annual Quality Assurance Assessment (AQAA) says, we make sure we talk with prospective residents and their families and give as much verbal information and paperwork as is necessary. A new brochure has been produced since that last inspection visit and a copy is given to prospective residents and their relatives. Some discussion took place with visiting relatives and a friend of another service user.They all commented that the pre admission procedure was satisfactorily carried out. It was clear that an adequate and sufficient pre admission process is in place, helping to give the assurance that individuals care needs will be successfully assessed and a decision is then made, in order to determine if the person needs can be met. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples care plans should contain sufficient and appropriate information that would inform the care staff of an individuals care needs. This would help ensure that a persons assessed needs would be met. Evidence: The previous Inspection Report highlighted the need for peoples care plans to contain more detail and guidance, in order to better equip the care staff. Four service users care plans were examined during this inspection and it was evident that the two most recently completed care plans contained specific detailed information. It was apparent that the information had been obtained from the initial admission assessment.The other two plans did not give enough detailed information, that would fully inform the care staff of the persons assessed needs. The manager said, we are updating all of the care plans to ensure that they all contain more detail.Care plans are reviewed monthly and the information obtained at the pre-admission assessment is used to form a basis for the care plans,further demonstrating the need to carry out thorough assessments. Individual records are maintained with regards to peoplesspecific health Care Homes for Older People Page 13 of 30 Evidence: care needs including visits from, GPs,district nurses,chiropodists and other health professionals. Records were also maintained for hospital, consultant and visits to the Doctors surgery. Monthly weight records for each individual are also maintained. It was evident that peoples health care needs are regularly monitored and any treatment needed is satisfactorily provided. There was a medication policy in place, clearly informing the staff the correct procedures to follow in the administration of medication. The medicine administration records were examined (MAR) and they were well maintained, with the name of the persons GP,chemist details and NOK at the front of each persons file. Each persons MAR chart had a photograph attached.This helps to avoid confusion and any potential medication error. There was an up to date list of trained staff who can administer medication with sample signatures and initials. Medication training certificates were also observed for the staff that were listed to administer medication. Unused medicines are being returned to the chemist with appropriate records being maintained. The medicines are stored in a secure locked cabinet, which was very well organised,clean and tidy. At the present time none of the service users administer their own medication, however there are agreement documents in place for anyone who wishes to take the responsibility for self administration. The members of staff on duty during the inspection visit were observed demonstrating a caring and respectful approach to service users. One person was observed wearing her nightwear throughout the day, it was commented that, she chooses to remain in her nightdress.It was suggested to the manager that every effort should be made that people are appropriately dressed, in order to maintain dignity and respect. The manager gave an assurance that people will be encouraged and enabled to maintain their dignity and respect. Care Homes for Older People Page 14 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a need to further increase the provision of meaningful activities,in order to provide motivation and stimulation to service users. Evidence: The AQAA states, All staff taking turns to do activities with residents, so as to get a varied amount of activities. There appears to have been a slight increase in available activities within the home,including two visits on a Monday and a Thursday of someone who provides an aerobics/chair exercise class. There was an activities programme displayed in the home, however there is no documented evidence to show that any activities take place nor is there any recorded names of the service users who may have participated. Some of the service users were having their hair done during the inspection and this was described on the activities programme as a days activity.The hairdresser was visiting in the morning time.No other activity was observed during the day. Some of the comments received from visitors were, Not a lot of activities going onand Theres not much happening, people just seem to sit around. The limited provision of activities has been raised before and the previous CSCI report stated, There needs to be a proactive move to ensure that individuals interests are Care Homes for Older People Page 15 of 30 Evidence: catered for and everything possible is done to provide motivation and stimulation, in order to promote peoples wellbeing. It is evident that there is still an insufficient provision of meaningful, stimulating and motivational activities. This was discussed with the manager and an assurance was given that the activities programme would be reviewed. There is an open house policy at Croft House and the feedback received, demonstrated that visitors are made very welcome at the home. Some of the comments were, If we are here at a mealtime, we are always offered a meal you can visit at any time and The day staff are absolutely wonderful, always make me welcome and offer me a drink. During the visit it was observed that people had brought some of their personal belongings into the home, helping to show that individuality is promoted. The home has a good reputation with regards the meals being provided. There was the opportunity to have a meal at the home and it was nutritious and appetizing. A discussion took place with one of the homes cooks and it was stated, We always give fresh fruit and vegetables. Some comments from service users and visitors were, the food is absolutely wonderful here The staff have managed to get her eating, its great shes eating more than everand the meals are really good. Good informative records are maintained in the kitchen, giving specific details of individuals dietary needs and peoples likes and dislikes. It was apparent that people are offered an alternative meal if they wish. Care Homes for Older People Page 16 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The continued lack of safeguarding adults training for staff is potentially placing vulnerable people at risk from harm or abuse. Evidence: There was a policy in place, which gave guidance about how to make a complaint or raise a concern that somebody may have. In discussion with visitors to the home, some of the service users and with some of the staff it appears that people are aware of how to make a complaint and would feel confident if there was a need to complain. No complaints have been received by the Commission (CSCI) since the last inspection visit. A policy was in place regarding, how to respond to the allegation or suspicion of abuse being made. New staff members are given some initial guidance on the safeguarding of adults,during their induction period, however it is still of concern that there is no formal specific safeguarding training being provided. A requirement regarding this training was made at the last CSCI inspection visit.This was discussed with the registered manager and an assurance was given that a trainer would be identified and this important training would be provided to all staff. This training is needed to help ensure that staff are knowledgeable and equipped to correctly deal with the protection of vulnerable people. Care Homes for Older People Page 17 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall the decor in the home is quite poor,failing to give a pleasant,clean and comfortable environment for people to live and work in. Evidence: A full tour of the home was carried out and it was evident that there is still a need for redecoration and refurbishment in many areas of the home. The dining room/conservatory extension has had new non-slip flooring fitted,which is safer and more hygienic.However the ceiling is still very unsightly with loose flaky bits of rotten wood and peeling paint hanging down,which is still a potential safety hazard.The radiators in the conservatory are also in need of being covered in order to reduce the risk of somebody getting injured. Radiators in some other areas of the home also need to be covered or removed, as was suggested to the manager, regarding the radiator in the passageway next to the staircase. The home has three lounges,all of which are in need of being redecorated,in order to bring them up to a reasonable standard.The lamp shades in the quiet lounge,leading into the dining room were observed to contain dirt and dead moths.Generally all of the communal areas were dusty,looking tired and are in need of being redecorated. The kitchen was found to be clean, hygienic and well organised.A new fridge has been Care Homes for Older People Page 18 of 30 Evidence: purchased since the last inspection visit,however the cabinet freezer,which is situated outside the kitchen is in need of being replaced. It is very rusty and leaking,which could be a health hazard. It was observed that service users bedrooms contained some of their own personal belongings, which helps people to maintain their own identity. It was also observed that many of the bedrooms are in need of being refurbished including, redecoration and some bedroom furniture needs to be replaced, due to it either being damaged or badly worn. It was also evident that incontinence aids were being stored in peoples rooms and in a couple of rooms this had reduced the actual floor space.Some boxes were stacked against a sink. This would make it quite difficult for someone to safely access the sink.The manager was informed that this practice does not promote safety, dignity or respect and alternative storage space should be immediately found. Some of the windows need to have restrictors fitted,in order to prevent accidents and to deter anyone illegally entering the home. The staff toilet on the ground floor did not have a toilet seat, which is unsafe and unhygienic. An assurance was given by the manager that these issues would be addressed. The previous report raised concern about inadequate lighting and the use of energy saving bulbs, it was concerning to see that they are still being used and one persons bedside lamp had a bulb sticking above the lampshade. This was also raised with the manager and it was suggested that all of the energy saving bulbs be replaced with conventional bulbs This would improve visibility and reduce the risk of falls. There was a new washing machine in the laundry,which was observed to be neat and tidy and it appears that the laundry is sufficiently equipped to meet the needs of the people living in the home. The previous report highlighted some concerns regarding the outside grounds. It was evident at this visit that the previous concerns had been addressed and the grounds were neat and tidy with appropriate facilities available for the collection and management of refuse. Although there have been some improvements to the outside grounds,the interior of the building is in need of redecoration and refurbishment. This will help ensure that people live and work in a home that is well maintained, comfortable, safe, clean and hygienic. Care Homes for Older People Page 19 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The recruitment procedures, particularly clearance checks need to be more robust.This would help ensure that only suitable people are employed to support and care for vulnerable people. Evidence: The staffing levels were examined and they were found to be satisfactory.There is an established staff team at Croft house. Four of the staff files were examined, including the last person to be employed at the home (June 2008).The criminal record bureau (CRB) checks were in place for only three of the four people.The explanation given for no CRB clearance for this person was that there has been a delay in receiving CRB clearances.The manager was advised to contact the CRB agency immediately, because of the time involved.It was also of concern that there were was no written evidence that the protection of vulnerable adults list had been checked (POVA list ). The manager said, we have applied for POVA checks,they just phone us now. The manager was informed that there is a need to obtain written evidence to confirm that these important checks have been carried out.This is needed for inspection purposes,in order to help ensure that only appropriate employees are employed to care for vulnerable people. The files contained other relevant information including, staff supervision notes, Care Homes for Older People Page 20 of 30 Evidence: induction material and some training certificates. The comments received regarding the staff were all positive including, the staff here are absolutely wonderful with her the day staff know her so well,they are excellent and it seems to be a really good team. There is still limited availability for staff training with only 25 of the staff having completed their national vocational qualification award (NVQ). At the time of the inspection visit none of the remaining staff had been enrolled onto an NVQ course.The manager acknowledged that staff training is presently very limited and an assurance was given that staff training would be a priority and a suitable training organisation would be identified. Care Homes for Older People Page 21 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and safety of people is not actively promoted and continues to place people at unnecessary risk from harm or accident. Evidence: The registered manager has managed Croft House for a number of years and is adequately qualified in the care profession. It was discovered during the inspection visit that the manager had a longer than normal holiday this year.The manager was informed that the CSCI must be informed of any periods of absence from the home that are longer than four weeks and also that the home must be appropriately managed on a day to day basis,if not by herself then a suitable arrangement should be made. There was some evidence that mandatory training is being provided, however as previously mentioned in this report and the last report, there is little evidence to show Care Homes for Older People Page 22 of 30 Evidence: that safeguarding adults training is being provided,therefore vulnerable people are potentially being placed at risk. It was commented that people look after their own finances or their relatives do. and receipts are maintained for any expense that people incur, for example hairdressing. All of the required health and safety inspection certificates were in place and up to date including, gas inspection certificate, electrical inspection certificate, fire extinguisher checks,stair lift and bath hoist, portable appliance testing (PAT) and a hazardous waste inspection certificate. It was identified at the last inspection visit that the owner was failing to carryout the required monthly inspection visits and send the completed report (regulation 26 ) to the CSCI. This is still the case,with no monthly reports being sent . It is also a requirement to inform the Commission of any bereavements or incidents within the home,although the Commission has received some of these notifications, it is clear that not all notifications regarding bereavements have been sent. It is apparent that there is a lack of consistency. The manager was informed of these shortfalls and an assurance was given that they will be addressed. It continues to be of concern that the health and safety of service users is compromised by the limited training made available and by the health hazards identified in the environmental section of this report. The manager was informed that appropriate action must be taken,in order to ensure that the health and safety of service users is actively promoted. Care Homes for Older People Page 23 of 30 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action 1 12 16 (2) (m) (n) The leisure and recreational activities for service users need to be improved. 31/12/2007 2 18 18 (1) (i) Staff to be suitably trained in 31/12/2007 `Safeguarding Adults? (Previous timescale not met) *The premises to be in a good state of repair internally and externally. *All parts of the home to be reasonably decorated. (Ongoing requirement) 28/02/2008 3 19 23 (2) (b) (d). 4 26 12 (1) (a)13 (4) (a)-(c)16 (2) (k) Promote and make proper provision for the health and welfare of service users. The home should be free from health and safety hazards. 31/12/2007 5 30 18 (1) (a) (c) Ensure that appropriate 31/01/2008 training is regularly provided, including safeguarding adults and NVQ training. Care Homes for Older People Page 24 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 A service users care plan should contain detailed information that is initially obtained at the assessment process. The care plan should also be kept under review. This is to help ensure that a personsassessed needs are clearly documented in their care plan, in order to give the carers the necessary information to provide a good quality service. 30/11/2008 2 10 12 The registered person shall 30/11/2008 make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users. People to be encouraged and enabled to be appropriately dressed, in order to promote dignity and respect. Care Homes for Older People Page 25 of 30 3 12 16 6(n) Consult service users about the programme of activities arranged by or on behalf of the care home and provide facilities for recreation including,having regards to the needs of service users,activities in relation to recreation,fitness and training. Meaningful and varied activities should be provided to promote stimulation and motivation. 31/12/2008 4 18 18 The registered person shall ensure that persons employed at the care home receive training appropriate to the work they are to perform. Safeguarding training is needed to help ensure that people are protected from harm or abuse. 31/12/2008 5 19 23 23 (2) (e) (f) (l)Suitable storage facilities should be provided for service users. This will increase floor space in bedrooms, helping to prevent falls and maintain and promote respect and dignity for vulnerable people. 30/11/2008 6 19 23 All areas of the home should 31/01/2009 be decorated to a reasonable standard. This is needed to provide a comfortable and pleasant environment. Care Homes for Older People Page 26 of 30 7 26 23 The home must be kept clean and kept in a good state of repair externally and internally. This will help maintain a safe and hygienic environment. 30/11/2008 8 28 18 The registered person should ensure that appropriate training is provided to staff. A minimum of 50 of the staff need to achieve the NVQ award at level 2 or equivalent. 31/01/2009 9 29 19 The registered person should ensure that all relevant Police clearance checks are made and available for inspection by CSCI. This to help ensure that everything possible is done to protect vulnerable people from harm. 30/11/2008 10 30 19 The registered person should ensure that at all times suitably qualified and competent persons are working at the home. Overall the limited training made available to staff is placing people at risk. 31/12/2008 11 31 12 The registered person should ensure that the care home is conducted so as: to promote and make proper provision for the health and welfare of service users. 30/11/2008 Care Homes for Older People Page 27 of 30 Ensure that the home is sufficiently and responsibly well run on a day to basis,in order to help ensure that peoples welfare is maintained and promoted. 12 33 26 Monthly visits carried out by 30/11/2008 the proprietor, with a completed report sent to the Commission. This is to ensure that regular monitoring of the service is being carried out, helping to ensure that the best interests of the service users are being monitored and considered. 13 38 13 All parts of the home to which service users have access are so far as reasonably practicable are free from avoidable risks;and unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. This will help ensure that service users are protected as much as possible from potential harm. 31/12/2008 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 16 It is recommended to make readily available a complaints leaflet/document, that gives all parties the opportunity to raise any complaints or concerns they may have. Care Homes for Older People Page 28 of 30 2 19 A refurbishment,decoration and maintenance programme should be maintained. Care Homes for Older People Page 29 of 30 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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