Inspection on 24/05/07 for Crossways Nursing Home

This inspection was carried out on 24th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Crossways Nursing Home 23/09/08

Crossways Nursing Home 26/09/07

Crossways Nursing Home 19/09/06

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Crossways Nursing Home Greywell Road Up Nately Basingstoke Hampshire RG27 9PJ Lead Inspector John Vaughan 24 th Unannounced Inspection and 25th May 2007 10:10 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 Crossways Nursing Home DS0000066923.V336186.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. Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Crossways Nursing Home Address Greywell Road Up Nately Basingstoke Hampshire RG27 9PJ 01256 763405 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) S.E.S Care Homes Ltd Mrs Rhonda-Lee Nancy Franklin Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (18) of places Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th September 2006 Brief Description of the Service: The home is owned by S.E.S. Care Homes Ltd who bought the home in May 2006. The home is situated in a quiet village near to Basingstoke. The home provides accommodation, personal and nursing care for up to eighteen persons aged 65 and over. The home can accommodate persons suffering from dementia type illnesses. Accommodation is arranged on two levels. The home has a pleasant lounge and dining room for the use of the residents. A large garden with an orchard is accessible to the residents. There are ten single rooms and four shared rooms; the majority of the rooms have en suite bathrooms. Fees for residency at the home range from £515 to £630 per week. Items not included by the fee include chiropody, hairdressing taxi fares and newspapers. Crossways Nursing Home DS0000066923.V336186.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 and involved the people living in the home, the manager, staff team, visitors and the area manager for S.E.S. Care Homes Ltd. The inspector examined records, spoke to staff and people living in the home and toured the building. Information was also received from care managers, general practitioners, and family members through surveys, telephone conversations and face to face meetings. The manager also completed an Annual Quality Assurance Audit (AQQA) and returned this to the inspector before he carried out the visit to the service. What the service does well: What has improved since the last inspection? What they could do better: The manager has been asked to review the care plans to improve the accuracy of information and put more detail into some of the instructions to make sure they meet people’s needs. Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 6 The activity programme needs to improve to demonstrate that people using this service have regular activity and stimulation to meet their assessed needs. The quality of the food provided in the home needs to be explored further to make sure people are happy with what is available and if this can be improved. The number of staff available in the home needs reviewing to make sure enough support is available for people to take part in activities and carry out other tasks such as the cleaning of the home. Staff recruited to the home must have all the checks carried out on their background to keep people safe. The provider has to make arrangements to implement a quality assurance programme to support people who use this service to contribute their views about the running of the home. The manager has been asked to provide safer means of holding doors open that protect people from fire. 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. Crossways Nursing Home DS0000066923.V336186.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 Crossways Nursing Home DS0000066923.V336186.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): 3, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who wish to move into this home can only do so following a full assessment of their needs and have opportunities to visit and tour the home to help with deciding if they want to move in. EVIDENCE: A file for the most recent person to move into the home had evidence that a full assessment of the person’s needs was completed before they moved into the home. An assessment from the care manager was also available. This information has been used to complete a care plan for the individual to meet their assessed needs. Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 9 The inspector spoke to family members who confirmed that they had received information about the service on behalf of their relative. They also visited the service, spoke to staff and were able to tour the home to help to make a decision about moving into the home. Crossways Nursing Home DS0000066923.V336186.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 adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made in the plan of care for individuals however further work is required to ensure that these plans are accurate and effective in meeting people’s healthcare needs. The medication administration practices of the home are unsatisfactory. EVIDENCE: Since the last inspection of the home concerns have been raised about the management of complex care needs of some of the people who have used the service. This has included the intervention to manage pressure ulcers and monitoring of the nutritional intake of individuals. Adult services and nurse advisors have worked with the home to address these issues and significant progress has been made by the manager and nurse team in making sure clear intervention strategies are in place. Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 11 The inspector looked at five care plans during his visit to the service. These all had details of the individual’s needs and a plan of care to support these needs. The inspector saw evidence of pressure care strategies and each of the plans examined for people who had identified pressure ulcers had a plan in place. Nursing records confirmed that the interventions are carried out at regular intervals. One plan was due for re-evaluation during the week of the visit and the nursing staff demonstrated awareness of this. Another record demonstrated the prompt identification of an ulcer, a plan was put in place and the nurse in charge stated that this wound has now healed. Fluid and nutritional charts are in place for all people in the home. One of the records examined by the inspector had contradictions between the fluid intake chart and the nutritional chart and the manager was advised to investigate this. None of the records showed any evidence of review and care plans put in place supporting the use of these charts did not have guidelines on the actions to take if fluid intake was poor. This could lead to the person not receiving prompt support with their fluid intake. The manager stated that the charts should have this information on and that an old chart has been used again. The manager agreed that care plans must contain this information. Moving and handling strategies are also in place however they lack detail in hoisting instructions. These plans must contain the details of the hoist to be used and the sling to avoid inappropriate equipment being used that could lead to the individual being injured. The manager told the inspector about the increasing immobility of one person who uses the service and they are no longer getting out of bed however when the inspector looked at the care plan for night routines this stated that the person gets out of bed for 1½ hours. This plan had only been reviewed in the last few days. The manager was advised that the review of plans ensures that the information is accurate and reflects the current needs of the person. The medication administration procedures and practices were examined with the nurse in charge. The medication is stored in a secure trolley, metal cabinet and locked fridge. A medication for pain relief was loose on the shelf. It was unboxed and the nurse in charge could not explain whom it belonged to. A number of gaps in the medication recording sheets were seen some of these gaps were due to the refusal of the individuals not wanting the medication that had not been correctly recorded by the nurses. The inspector noted a sign above the medication fridge stating that the temperatures should be taken daily. The record is poorly completed with large Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 12 gaps in the monitoring chart. The temperatures had only been monitored three times in the last month. These shortfalls in the medication administration practices have the potential to lead to further errors in the process placing people who use the service at risk. Crossways Nursing Home DS0000066923.V336186.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. People who live in this home do not have enough opportunity to engage in meaningful activities that meet their needs. Meals are provided based on a menu that has been chosen by people who live in the home however the quality of this food needs to be explored further by the provider. EVIDENCE: The inspector spoke to service users, staff and the manager about the activities and experiences of people who use the service. A notice board contained information on a visiting library and a member of the clergy visited the home to meet people in the home and celebrate communion. The inspector spoke to this visitor who said that they visit on a monthly basis to chat to individuals and provide spiritual support. Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 14 Each of the people’s plans the inspector examined had documented the needs of people in a plan called “work and play”. People’s likes and dislikes are recorded and the plan encourages people to pursue their interests. The home employs an activity co-ordinator who is away on holiday at present. The manager stated that this person is also completing a National Vocational Qualification (NVQ) and is spending some of their time providing care to complete the award. During the two days in the home little activity took place for people, a number of people stay in their rooms due to poor health and some people have chosen not to sit in communal areas and the staff respect these wishes. All carers told the inspector that very little activity is organised and no arrangements have been made to cover the absence of the activity worker. Staff also said that the activity worker spends most of their time on the care side and has about half an hour before lunch to work with the people in the home. Carers said that they try to chat to people as the provide support but the pressure of meeting the personal care and nutritional support means that they have little time to do anything else. The inspector asked people about activities they had taken part in recently and the response was “not much”. The manager noted on the Annual Quality Assurance Assessment (AQAA) that they want to improve this area with more activity and keeping records of what people take part in. The inspector spoke to visitors and received feedback from family members in surveys returned to the commission to confirm that people are supported and encouraged to maintain contact with families. There are no restrictions on visiting and important relationships are recorded in the individual’s care plans. Lunch was observed during the visit and a member of staff supported a group of people sitting in the dining room to eat their meals. The staff member was observed actively encouraging people to eat and have seconds in the form of extra deserts. A number of people have their meals in their room and staff were busy supporting these people on a one to one basis. Some people are not eating and have fortified drinks to help maintain their well-being. The cook has changed the menu to ensure meat alternatives are available to people as recommended at the last inspection and a four-week menu is in operation that contained a good range of meals. The inspector was told that the food no longer comes from a large catering supplier and is now purchased from a supermarket chain. Fresh meats are purchased and frozen for later use. The cook expressed concern about the quality of the food they have to purchase due to the limit on the housekeeping budget and the inspector saw a delivery of food that was mostly from the company’s low cost value range. Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 15 The area manager refuted this and stated that there is no limit on the food budget and quality food is a priority including the supply of fresh vegetables and meat to the people who live in the home. The inspector advised that the manager examine the current practises to ensure the food quality is meeting the dietary needs of the people who use the service. One person said that they didn’t like the bread they had been given and their sandwich was dry. Families told the inspector that they always felt the meals were of good quality however a visiting health professional raised questions about the quality of the food and questioned if it could be contributing to the lack of appetite of some people in the home. Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The practice of the home ensures that concerns and complaints are recorded and responded to promptly. EVIDENCE: The home has a complaints procedure and this has been made available to all people who use the service. The inspector examined the complaints record of the home. There have been ten complaints in the last twelve months. A number of these have been made by staff and are related to employment issues. The file contained correspondence for each of the complaints. Family members told the inspector that they knew who to raise concerns with if they have any problems. The manager was advised to put a monitoring log in place to demonstrate how the complaints process has been followed and what the outcome was. The inspector spoke to staff about adult protection and the responses confirmed that any concerns would be reported to a senior person in the service. None of the staff recalled training in this area. This was discussed with the manager who stated that training has been provided and it is included in the induction to the home. Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 17 The manager was advised to revisit adult protection procedures with their staff team at their next staff meeting to ensure everyone is up to date on the policy and process to follow. Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 18 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. People live in a homely and comfortable service however work is required to make sure the health and safety of the service is maintained. EVIDENCE: The inspector toured the home assisted by the manager. The home is in a generally good state of repair however some areas need redecorating and repair. The manager stated that they are arranging for the floor in the dining room to be replaced, as this is soiled and not suitable for the needs of the home. Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 19 There is a homely atmosphere and people who spoke to the inspector said that they liked the home and felt comfortable. People have been able to bring in their own furniture and belongings to maintain this homely feel. A number of single rooms have had their beds positioned across the narrowest part of the room to allow for better access for staff either side of the bed and moving and handling equipment. A new call system has been installed and the inspector observed the call switches within easy reach of people who remain in their beds. The manager had to reposition one of these cords as it had been placed around the person in a way that could lead to the individual becoming entangled in the cord. The inspector advised that this would need to be noted in the risk assessment for people to keep them safe. During the tour of the home the inspector observed a number of doors wedged open. The use of wedges on doors is not acceptable and has the potential to contribute to the spread of smoke and fire placing people at risk. The manager will need to consult with Hampshire Fire and Rescue service’s fire safety officer on more suitable means of keeping doors open. The side entrance of the home is used as the main entry to the home and during the visit the inspector saw staff and visitors bolting this door. The door is also a designated fire exit and should not be locked in this way. The manager said that this was bolted to prevent a person wandering out of the home. The manager also said that it had been agreed to put an alarm system on this door, this was confirmed by the area manager who had expected this work to have already been completed. The home has a laundry room and a sluice facility. The home was free from unpleasant smells and this was mentioned by a number of visitors. Staff were seen wearing gloves and aprons and cleansing gels were regularly used by staff to limit the possibility of spreading infection. Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 20 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. People are supported by staff who have been trained and in most cases supervised however the recruitment practices and staffing levels do not meet the needs of people who use the service. EVIDENCE: The inspector examined the rota and this was discussed with the manager. At the time of the visit thirteen people are living in the home and the manager stated that in the morning one trained nurse and four care staff are on duty. This reduces to one trained nurse and two carers in the afternoon. One trained nurse and one carer cover night duty. The shift timing does not allow any crossover time and any handover of information has to take place in the staff member’s own time. This is not good practice and relies on staff good will to ensure important information is passed to the next team on duty. The manager was advised to look at the shift planning to remedy this concern. The staffing for the week of the visit used the staff member who usually is responsible for cleaning the home to provide care. This has meant that the Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 21 cleaning duties have been neglected. The rota demonstrated that the cleaning staff and activity worker were both being utilised as care staff. The manager stated that two new carers have been employed and this would help with staffing in the longer term however they are both new to the care field and this is their first week of employment. Both of these staff were on duty and counted in the numbers during the visit to the service. The staff team spoke to the inspector and all said that morale is low and the current staffing levels do not allow any extra support for service users in activities or spending one to one time with people. Staff also stated that the activity worker spends most of their time on the care side leaving little time for activities. A healthcare professional also raised the issue of staffing levels and they had concerns that not enough was being done to meet all of the needs of people who use the service. The manager has a level of staff in place that meets the care needs of the people living in the home however this is to the detriment of other practices in the home and they were advised to review their current practices. The inspector examined the recruitment records for staff. Most files had all information required including two written references, application forms, proof of identity and evidence of the completion of a Criminal Records Bureau (CRB) check. One file examined for a trained nurse did not have evidence of the returned CRB, this person had a Protection of Vulnerable Adults (PoVAfirst) check. The manager could not explain this and could not confirm if this CRB had ever been returned. The manager stated that this person has worked unsupervised taking charge of night shifts on at least five occasions. As part of the response to concerns about care practice in the home a number of training courses have been undertaken recently and these included tissue viability/ wound care, pressure care, nutrition, passive limb movement, continence and first aid. The home has nine staff with a NVQ 2 or above and a further five staff in the process of completing this award. Mandatory training is in place including fire safety, moving and handling and health and safety. The inspector spoke to a new member of staff who confirmed that they are undertaking their induction programme at present. Staff who work in the kitchen have had training in food handling and the cook is undertaking training in nutrition. Staff confirmed that they receive regular training and that supervision takes place with the manager or senior staff member on a regular basis. The Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 22 manager has just started supervision of the trained nurses working in the home and has completed two out of eight to date. Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 23 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, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The current practices of the home do not demonstrate that the service is well managed and the quality assurance programme needs work to demonstrate it is effective in supporting people who use the service and their representatives to contribute to the running of the home. The practice of propping open doors has the potential to place people at risk. EVIDENCE: The inspector received positive feedback about the character of the manager from family members who were visiting at the time of the inspection. The Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 24 manager is a first level nurse, has experience of running the service they have also completed their registered manager’s award. A number of areas have been highlighted within this report including the effectiveness of care planning, management of medication, staff allocation and recruitment of staff that are directly related to the management of the home and need to be addressed to demonstrate that the home is effectively managed. The home’s last quality assurance audit and survey was undertaken with the last provider and their was no evidence of any programme put in place to evaluate the service with the new provider. The area manager confirmed that a process exists and they would talk to the manager about starting this process. They stated that at present the manager was concentrating on responding to the requirements of Adult services as part of the recent adult protection concerns. The inspector was told that the home does not hold for safekeeping or manage any monies for people who use the service and any additional costs such as hairdressing or chiropody are invoiced to the individual or their representative. When examining the medication storage the inspector found an envelop with receipts and change for a person living in the home. The nurse in charge thought that a staff member had done some shopping for the person. The manager was advised to look at the day-to-day practices in the home and make sure they meet their policy of safe handling of people’s monies for the protection of the individual and staff concerned. The servicing records confirmed that heating, hot water and alarm systems are regularly serviced. The manager has had all pressure relieving mattresses serviced and evidence that the hoists and lift have also been inspected and serviced was seen. The inspector spoke to the manager and area manager about the propping open of doors and the bolting of a designated fire exit. Further advise will need to be obtained from the fire safety officer and suitable door openers will need to be installed. The area manager stated that they would chase up the installation of the alarm on the door and remove the bolt. Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 25 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 X 3 X X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 15 Requirement People who use the service must have a care plan that accurately reflects their assessed needs. Fluid and nutritional charts must be completed fully to ensure people are receiving adequate intake of fluids and food. The use and response to this record must be accurately documented in the individual’s care plan. 3. OP7 13 (5) The moving and handling guidelines must have clear information on the type of hoist and sling to be use for each person. Medication administration records must be recorded accurately at all times. Medication must be kept in its original box and if no longer required it must be disposed of. 01/07/07 Timescale for action 01/07/07 2. OP7 12(1) 01/07/07 4. OP9 13 (2) 01/07/07 5. OP9 13 (2) 01/07/07 Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 27 6. OP12 16(2)m,n People who use this service are provided with activities and stimulation to meet their assessed needs. The agreed activities and strategies to achieve this must be documented in the person’s care plan. 20/07/07 7. OP15 16(2)i The current foodstuffs purchased to provide meals is reviewed with the dietician to ensure it meets the nutritional needs and expectations of people who use the service and their representatives. 20/07/07 8. OP27 18 The number of staff on duty in 01/07/07 the home must ensure that the needs of people using the service are met. This must include the recreational needs of people and adequate provision of staff to maintain the hygiene of the home. All staff employed in the home must have a full CRB check before working unsupervised. The home must have a quality assurance programme that ensures people who use the service and their representatives can contribute to the running of the service. The propping open of doors is reviewed with the fire safety officer and suitable systems are put in place to maintain the safety of all who live and work in the home. 8. OP29 19 01/07/07 9. OP33 24 20/08/07 10. OP38 23(c) 01/07/07 Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Crossways Nursing Home DS0000066923.V336186.R01.S.doc Version 5.2 Page 30 - 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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