Inspection on 20/12/06 for Croft (The)

This inspection was carried out on 20th December 2006.

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

Croft (The) 10/10/08

Croft (The) 15/10/07

Croft (The) 27/02/06

Croft (The) 22/09/05

Croft (The) 28/09/04

Croft (The) 26/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Croft Walsingham Way Eye, Peterborough PE6 7XB Lead Inspector Nicky Hone Key Unannounced Inspection 10:30 20th December 2006 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 The Croft DS0000035244.V293524.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. The Croft DS0000035244.V293524.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Croft Address Walsingham Way Eye, Peterborough PE6 7XB 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) 01733 222448 01733 223895 Greater Peterborough Primary Care Trust Jill Frances Waywell Care Home 39 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (6), Old age, not falling within any other of places category (39), Physical disability (3) The Croft DS0000035244.V293524.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th February 2006 Brief Description of the Service: Purpose-built in the 1960s, The Croft is in a residential area in the village of Eye and offers a home to 39 older people. The home is on two floors and all areas are accessible to people who use wheelchairs. On the ground floor there are three lounges with dining areas, toilets, bathrooms and some single bedrooms, as well as a main kitchen, laundry, smoking lounge and office. Upstairs there are single bedrooms, a quiet lounge, toilets, bathrooms and the manager’s office. All bedrooms have a washbasin and are comfortably furnished. The home is set in pleasant gardens, and is within walking distance of local shops, pubs and churches. The city of Peterborough, with its wide range of leisure facilities including a large shopping centre, restaurants, cinemas and a theatre, is within a few minutes drive or bus ride. Good roads and rail services link Peterborough to London and other major cities. Service users’ financial status is assessed so that they pay what they are deemed to be able to afford, up to a maximum of £371.00 per week. Additional charges include hairdressing, chiropody, newspapers and any personal items such as toiletries, alcohol, tobacco and clothing, as well as some outings. Copies of the CSCI inspection reports are available in the foyer of the home. The Croft DS0000035244.V293524.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We, the Commission for Social Care Inspection, carried out an inspection of The Croft over two days, 20/12/06 and 15/01/07. Over the two days we spoke with service users, relatives and staff, had a look round the building and checked some of the records kept by the home. There were 35 service users in residence, all of whom were over 65 years of age. Since the last inspection the ownership of this home has moved from the Greater Peterborough Primary Care Partnership to the Greater Peterborough Primary Care Trust (GPPCT). All management arrangements for the home have remained the same. What the service does well: This home is run well and generally service users are comfortable and happy at The Croft. We spoke with relatives who told us that “the staff are all very nice, and kind to our relative. There is nothing they could do better”. A service user said, “We are very comfortable here. Staff are kind and do as much as they can”. There is information about the home available for new service users and full assessments of their needs are carried out. Care plans are in place for all service users and there was evidence that service users are cared for well, their healthcare needs are met, and their privacy and dignity are respected. Medicines are administered correctly. Friends and family are welcomed at The Croft and the activities coordinator arranges outings and entertainment. Everyone we spoke with commented on how good the food is. Service users can have a cooked breakfast if they want one, there are choices to suit all tastes for lunch and tea, and staff offer assistance to people who need it in a sensitive way. There is information available on how to complain and service users know that if they have any concerns these will be dealt with. Staff receive training in Protection of Vulnerable Adults. Generally the home is pleasantly decorated and comfortable, and service users can bring their own possessions into their rooms. The procedures for recruiting and vetting new staff are good, and staff receive training and supervision to make sure they can do their jobs well. There is an excellent procedure in place to make sure agency staff are suitable. The Croft DS0000035244.V293524.R01.S.doc Version 5.2 Page 6 The home makes a lot of effort to check out with service users and their relatives that it is providing the service which people want, by sending out questionnaires and holding meetings. The majority of records are completed well and health and safety is given high priority to make sure that service users are safe. 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. The Croft DS0000035244.V293524.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 The Croft DS0000035244.V293524.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, 2, 3, 5 Quality in this outcome area is good. Service users know that the home will be able to meet their assessed needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the home’s statement of purpose and service user guide are kept on display in the entrance hall. Both these documents contain good information about the home, but both are in need of review to ensure they are up to date. Each service user has a copy of the information in a folder in their room. Care managers (social workers) complete an assessment document for each person who is offered a place at The Croft. This document gives detailed information about each aspect of the care a person might need, and the way that care should be given. When the person moves into the home, the The Croft DS0000035244.V293524.R01.S.doc Version 5.2 Page 9 assessment document becomes the care plan. There was a completed assessment on all the files we looked at. Relatives told us that staff from the home had visited their relative at her own home before they offered her a place at The Croft. They had been given information about the home and they had been able to come and have a look round. The Croft does not offer an Intermediate Care service. The Croft DS0000035244.V293524.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, 10, 11 Quality in this outcome area is good. The staff team is committed to offering good quality care so that service users’ personal and health care needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager said she feels the care being offered to the service users has been improving and is now very good. A new system has been introduced so that staff work in teams, and each shift each team knows which service users they are looking after. This has proved less institutionalised and the staff have become even more dedicated. Handovers are held between each shift and all staff hear the handover about every service user. The Croft DS0000035244.V293524.R01.S.doc Version 5.2 Page 11 When a person moves into the home, the assessment document becomes the care plan. These documents generally contain good information, but we found that because those we looked at had not been dated and signed, we were not sure that the information was up to date. We looked at the care plan records for four service users. One contained the detailed plan which appeared to cover all aspects of care, including guidance for staff on how to manage challenging behaviour. However, there were gaps in the information. For example, the care plan relating to bathing did not specify how often the person would like a bath, or when (time of day, day of the week and so on). The record of bathing showed that the person had had five baths in five months: on one day it was recorded in the daily notes “…enjoyed the bath”, indicating that the person might want a bath more frequently. Another part of the plan referred to skin problems, but this was not cross-referenced with the care plan about bathing. One of the charts which had been put in place to record an aspect of this person’s care had not been completed fully: if charts (in this case a record of bowel movements) are started but not fully completed, there could be serious consequences. The second file we looked at contained an “Assessment and Care Plan”: this document was not signed or dated and there was no way of telling whether this document had been updated recently or was the same as when the person was admitted three years ago. The care plan relating to bathing stated that this service user liked a bath every week: the record of bathing showed that only three baths had been given in seven weeks. A moving and handling risk assessment on this file, completed in 2003, gave no indication at all that this person is now a wheelchair user. The risk assessment had been updated by the second day of the inspection and the manager said the care plans would be re-written by the end of January. The third file, of a service user who had moved from another of GPPCT’s homes, contained the assessment/care plan but there was no way of knowing whether it had been completed at The Croft or at the other home, as it was not dated or signed. Staff make daily notes in each person’s records but we saw examples of when these did not give any meaningful information about the person and were quite negative. For example, there were several entries of “no problems”. There were records on each of the files seen which showed us that service users are able to see a range of other professionals, such as the doctor, district nurses, chiropodist, optician and dentist, so that their healthcare needs are met. We were pleased to see that reviews of one of the care plans had been carried out monthly, with the last review at the end of November. Two others had not The Croft DS0000035244.V293524.R01.S.doc Version 5.2 Page 12 been reviewed since September. These reviews are done in a thorough, meaningful way, involving the service user whenever possible and are recorded on a separate review document. However, there was evidence that sometimes changes are not transferred to the care plan document. A copy of the review is sent to the service user’s relatives. Medicines are kept in locked trolleys which are bolted to the wall in the lounge during the day, and in a locked cupboard at night. The home uses a weekly Nomad system: records of administration were signed correctly. At the time of the inspection only the assistant managers had been trained to administer medicines, but there were plans to train care staff so that medicines can be administered on a more personalised basis to suit the choices made by each individual resident. All the assistant managers have had training in medication administration, and a recent refresher course. A new system has been put in place to ensure that service users who are ill in their rooms, or decide to spend days in their rooms, are given appropriate care. A folder is put in the room with “TLC charts” which carers complete to show when care is given. The managers are also looking at current information about Care Pathways for end of life care. The Croft DS0000035244.V293524.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, 15 Quality in this outcome area is good. Service users are able to make choices about how they live their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One of the assistant managers coordinates the activities that take place at The Croft. Quite a few entertainers are booked to come to the home, some outings are organised, and a number of spontaneous activities take place. Amongst other things, a gentleman has started coming in who does Sport for All. He organises competitive games for the service users which are much enjoyed. One person said he enjoys helping in the garden, digging, planting and cutting the hedges, as well as doing things like playing games and attending the church service. He felt there is enough to do. Other service users and relatives we spoke with also felt that the staff do their best to provide activities to keep people occupied during the day, but a couple of people said they do The Croft DS0000035244.V293524.R01.S.doc Version 5.2 Page 14 get bored sometimes. On the first day of the inspection, several service users went shopping with staff to the city centre. Staff felt they would like more time to do activities with the service users. The Croft operates a 5-week lunch menu which gives a wide range of nutritious and healthy meals, including a lot of fish dishes. There is a choice of two main meals at lunchtime, or service users can choose from the ‘Choices Menu’ which includes jacket potatoes, omelettes, pasty, and salads. Service users make this choice the previous day. Service users can have a cooked breakfast every day if they want to. On the second day of the inspection the manager said she and the cook had been getting ideas together for a vegetarian menu. Menus are discussed at the residents’ meetings, as well as the cook talking to each individual service user about their likes and dislikes. Service users, relatives and staff all said how much the service users enjoy the food, and the meal seen on the day of the inspection (chicken pie or omelette) was well presented and looked delicious. We saw carers sitting with service users who needed assistance with their food, and taking time to help as much as was needed, and at the service user’s pace. The kitchen was checked briefly and was clean and well-stocked. Food in the store cupboards and fridges was neat and tidy and included dates, either a best before date, or the date food such as cheese had been opened and put in the fridge. The Croft DS0000035244.V293524.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, 18 Quality in this outcome area is good. Service users are confident that their concerns are listened to and that staff know how to protect them from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We saw leaflets in the entrance hall, and information on notice boards, telling service users, their relatives and any other visitors to The Croft how to make compliments or complaints about the home. Service users and relatives we spoke to felt they would be able to raise any issues if they needed to with the manager or assistant managers, but all said they had not needed to. They felt their concerns would be sorted out. The most recent complaint made to the home, which mainly raised concerns about another service, had been investigated well and the complainant was satisfied with the outcome. All staff undergo an Awareness of Protection of Vulnerable Adults course during their induction. The Croft DS0000035244.V293524.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, 26 Quality in this outcome area is adequate. Generally the environment is of an acceptable standard but additional toilets are needed so that service users feel more comfortable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is reasonably well decorated and comfortably furnished. Since the last inspection the carpet in the smoking room has been replaced with hard, burn-proof flooring. There are some areas which need decorating: we discussed this with the manager. The ceilings in the lounges are especially in need of attention. Bedrooms are decorated when they become vacant, and at the time of the inspection the handyman was decorating the toilets throughout the home. A maintenance/decorating plan is kept. The Croft DS0000035244.V293524.R01.S.doc Version 5.2 Page 17 Several people, service users and staff, told us that they find it very difficult that there are only two toilets near to the lounges (where most of the 35 service users spend their day). Other toilets, at the end of long corridors, are quite a distance to walk from the lounges, and are not big enough for wheelchair users. We asked the manager to think again about whether there is a way that more toilets could be provided in this area. There was a large gap at the top of the door to one of the lounges. We asked the manager to get advice from the fire authority on whether this is acceptable. Service users told us that their rooms are comfortable, and they are able to bring in their own possessions if they want to. Most of the rooms we saw were nicely personalised. The home was very clean and there were no unpleasant odours. The Croft DS0000035244.V293524.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. Staff recruitment, training and supervision are good but there are not always enough staff to give service users the best quality of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager said that staff recruitment has been quite difficult, but three new staff have been appointed recently and will start as soon as all the required documents are in place. The manager said the staff team are very good at working extra shifts whenever they can to make sure the shifts are covered. Service users praised the staff, saying they all have to work very hard. They, and the staff we spoke with, said there are not always enough staff: although the ‘jobs’ get done, it would be better if staff could spend more time with service users and have time to do more activities. Sometimes agency staff are employed to cover shifts. The home tries to use agency staff who have worked at the home before so they are more familiar with the service users, the building and the routines. There is currently one agency staff member who is working full time at The Croft. The home has an excellent procedure in place for ensuring that agency staff are suitable. The The Croft DS0000035244.V293524.R01.S.doc Version 5.2 Page 19 home insists on receiving a profile of the staff member, which includes a photo, evidence that references and Criminal Record Bureau checks were satisfactory, and a record of the training the person has received, before they start their shift. Each agency worker has to complete a questionnaire on arrival, and a brief induction. Staff spoken with said they have received training (including refreshers) in the majority of mandatory topics. One person said she was about to take a course on infection control, and a refresher course on medication. On the first day of the inspection the manager told us that although she knew that all staff have received all the mandatory training they should have, the records to show evidence of this were not up to date. She worked hard on this and by the second day the records were improving, with clear matrices in place to show at a glance which staff had attended which courses and when. All staff undertake moving and handling training every 18 months; food safety training, with a refresher course every 3 years; and a 3-day course on challenging behaviour. Fire safety training is covered twice a year by an external trainer for one session, and video training for the second session. Fire drills are held: by the second day of the inspection the manager had devised a chart to record staffs’ attendance at a fire drill so she can make sure that all staff are involved in at least one drill each year. Infection control and first aid are covered during induction for all staff: managers and night staff all go on to complete the 4-day first aid course so that there is always a qualified first aider on duty. Seven staff have been awarded a National Vocational Qualification (NVQ) in care, one person is currently undertaking NVQ level 3, one level 4, and 2 staff will start level 2 shortly. Medication training is given to the managers by Boots (see Health and Personal Care section of this report). This training is now also being offered by an NHS trainer: all staff will be assessed on their competence which will include knowledge of the medication policy as well as practical administration. We looked at the personnel files for two staff members. All the information required to ensure that service users are protected from harm was in place on both files, showing that the home follows a good recruitment and vetting procedure. The Croft DS0000035244.V293524.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38 Quality in this outcome area is good. This home is run well. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This inspection demonstrates that the registered manager is capable of managing the home well. She is currently undertaking NVQ level 4 in care. Staff, service users and relatives we spoke with said they find the manager easy to talk to and to work with. The manager supervises the assistant managers regularly, in individual and group sessions. The Croft DS0000035244.V293524.R01.S.doc Version 5.2 Page 21 The GPPCT has a good quality audit system in place which includes sending out an annual questionnaire to all service users and relatives. The responses are collated into a report, and comparisons made across all six GPPCT homes, and with previous years. As well as this, each month, a few service users are selected to answer questions about a particular topic, for example food, the environment, or privacy. Service user meetings are held, and the manager is planning to set up a regular open session for service users and their families. Any issues raised are addressed as quickly as possible. Staff at The Croft put together a quarterly newsletter, called the Croft Commentary, and another newsletter is compiled for all 6 homes by the GPPCT’s Resources Manager. These are a useful way of ensuring that everyone is kept up to date with whatever is going on. Some service users ask for small amounts of money to be held in the safe. Good, detailed records are kept. We checked the cash and records for two service users: one was correct. There was a mistake in the calculations on the second one which meant that the cash and the balance did not tally. The manager checks the record at the end of each page: for some people who do not use their account very often this might not be for several months. We recommended that this is done more frequently so that any mistakes can be recognised sooner. Staff told us that they have regular one-to-one supervision sessions with one of the managers, and staff meetings are held regularly. Staff rotas are kept up to date and show accurately which staff have been on duty. As with all records, correcting fluid must not be used on the staff rota. An outside company has been contracted to visit the home weekly to test the fire alarm and emergency lighting systems. We checked the records which showed that these tests had been carried out weekly/monthly as required, except for a slight gap around Christmas. The manager said she would work out a way of ensuring there were no gaps. The manager carries out a monthly health and safety audit of the home. Risk assessments, covering all aspects of any activity in the home, are written and reviewed. Records to show that hoists had been checked were not available, but one of the hoists had a sticker on it showing that it had been checked in August 2006. The Croft DS0000035244.V293524.R01.S.doc Version 5.2 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 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 2 3 2 3 The Croft DS0000035244.V293524.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP7 OP19 Regulation 15 23(2)(d) Requirement Care Plans must be kept up to date. All parts of the home must be reasonably decorated. The ceilings in the lounges must be decorated. The registered persons must ensure that there are an appropriate number of toilets in suitable places to meet the needs of the service users. A plan to provide sufficient toilets near to the lounges must be submitted to the CSCI within the timescale. The registered persons must ensure that at all times a sufficient number of staff are working at the home to meet the needs of the residents. Records of money held for service users must be accurate. Timescale for action 31/03/07 31/03/07 3 OP21 23(2)(j) 31/05/07 4 OP27 18(1)(a) 31/03/07 5 OP35 16(2)(l) 15/01/07 The Croft DS0000035244.V293524.R01.S.doc Version 5.2 Page 24 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 2 Refer to Standard OP12 OP19 Good Practice Recommendations The manager should ensure that the range and number of activities offered to service users continues to improve. The manager should ensure that the programme of decoration and maintenance of the home continues as planned so that the home is maintained well. Staff training records should be kept up to date at all times to provide evidence that staff have received sufficient, appropriate training. Records of financial transactions made on behalf of service users should be checked more frequently to ensure they are correct. Correcting fluid should not be used on any records. 3 OP30 4 OP35 5 OP37 The Croft DS0000035244.V293524.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 The Croft DS0000035244.V293524.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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