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Inspection on 01/11/05 for Crossways Residential Home

Also see our care home review for Crossways Residential Home for more information

This inspection was carried out on 1st November 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents spoken to during the inspection made very positive comments about their care at Crossways. They feel they are given the opportunity to exercise choice and there is clear evidence of a flexible approach, which recognises the wishes of individuals. Some of the comments of the residents are as follows: "It`s lovely in here". "I get up when I like, I have breakfast in bed." "They look after us very well." "We have everything we want. We don`t want for nothing. I would recommend this place to anyone." There are good assessment procedures in place and a good system for care planning. There is a good training record, with staff making progress with NVQ qualifications and other appropriate training being regularly arranged.

What has improved since the last inspection?

What the care home could do better:

The home needs to improve the way it consults with and involves residents in their care planning. There are still some areas with regard to medication administration and recording which need improvement, particularly with regard to the quality of the administration sheets and the obtaining of clear instructions from the prescribing G.P. Social care activities are still not taking place with sufficient regularity and some residents still say they are bored. A DVD has been purchased through monies raised by staff, but there is very little equipment available for activities. As at the last inspection, the home is not offering a clear alternative for the main meal of the day. Some concern was voiced about a decline in the quality of the meat at the home. Further consultation needs to take place with residents with regard to both social care activities and food. Although there have been great improvements in the environment of the home, the kitchen remains outstanding and needs refurbishment. The drive must be made good, as currently it is hazardous.

CARE HOMES FOR OLDER PEOPLE Crossways Residential Home (All paperwork to Penn) 66 Highgate Road Highgate Walsall West Midlands WS1 3JE Lead Inspector Maggie Bennett Announced Inspection 1st November 2005 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 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 Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Crossways Residential Home Address (All paperwork to Penn) 66 Highgate Road Highgate Walsall West Midlands WS1 3JE 01922 646168 01922 646168 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) Obsan Limited Care Home 21 Category(ies) of Dementia (9), Old age, not falling within any registration, with number other category (21) of places Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Maximum number of service users at any time shall not exceed 21 (Twenty-One). 21st June 2005 Date of last inspection Brief Description of the Service: Crossways Residential Home provides accommodation and personal care for 21 people over the age of 65, 9 of whom may have dementia. The property is currently undergoing extensive refurbishment. When completed, the home will provide accommodation for 23 people in 19 single rooms and 2 double rooms. 12 of the bedrooms will have an en suite toilet. All rooms have a wash hand basin. As well as an increase in bedrooms an additional lounge area, 2 assisted bathrooms plus an assisted shower room have been created. There is an attractive garden to the rear of the property. Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on a weekday between 8.30 a.m. and 6.00 p.m. Prior to the inspection comment cards were sent to residents and their representatives and 6 were returned to the Commission. In addition the home forwarded a Pre Inspection Questionnaire. During the inspection several residents were spoken to and discussion also took place with individual staff members, the home’s Acting Manager and the company’s Area Manager. The care plans of a random sample of residents were seen. In addition various documents were inspected. At the last inspection 20 statutory requirements were made and it was found on this occasion that 13 of those requirements had been met. A further 9 statutory requirements were made at this inspection. Since the inspection in June 2005 the then Acting Manager has resigned and another Acting Manager is now in place. What the service does well: What has improved since the last inspection? One of the residents was particularly pleased that staffing levels had increased. This person said: “It’s better now, there are enough staff.” Staff, too, had seen the benefit of increased staffing levels and also felt that staff morale was better and that they were working well as a team. One person felt that the problems the home had recently experienced, particularly around the sudden departure of the former Acting Manager, had now been resolved. The standard of décor within the home continues to improve and several of the residents expressed their satisfaction with the new surroundings. When all the work is completed, the home will provide a comfortable and very pleasant environment. The provision of a second assisted bathroom is very much welcomed. Standards of cleanliness were much improved since the last inspection. Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 6 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. Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 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 Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 There are good assessment procedures in place to ensure that no resident moves to the home unless the home is sure that it can meet their needs. Following assessment the home must, however, confirm this in writing to the resident. EVIDENCE: Standard 1 was not inspected in detail at this inspection and is, therefore, not scored. It was noted, however, that a new Statement of Purpose and Service Users’ Guide has been produced to reflect the increase in beds and facilities at the home and the change in management. The assessment information of two newly admitted residents was seen at the inspection. This showed that a full assessment had been sent to the home prior to the person’s admission and that the Acting Manager had visited each person and carried out her own assessment. Following the home’s assessment the Manager must write to the prospective resident confirming that the home is able to meet their needs. At present assessment information is kept Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 9 separately from the care plan and it is recommended that all this information is kept together, in a file with an index and dividers. Although Standard 4 was not assessed, the Acting Manager did feel that among the 14 residents currently at the home, the 9 places for people with dementia were taken. Standard 6 is not applicable as the home does not admit residents for intermediate care. Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. The home has a good care planning system in place. In order to ensure that residents’ personal and healthcare needs are fully met, they must be given the opportunity to be more involved in the reviews of their care plans. Although medication administration has improved, the home needs to ensure that they are obtaining clear instructions from their Pharmacist in order to ensure that residents are protected and that their medication needs are met. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: The care plans of 5 residents were seen during the inspection. There was evidence that care planning has improved since the last inspection, with all plans seen indicating individual needs and how these needs are to be met. Plans seen contained a risk assessment, including assessments with regard to the risk of falls and developing pressure areas. The plans included evidence of monthly reviews, which were signed and dated. Where possible, these reviews must be conducted with the resident and signed by them. When six monthly or annual reviews are held by social workers, the home must insist on copies of the notes from these meetings. As stated above, it is recommended that all care plan information is kept in an individual file for each resident and includes an index and dividers. Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 11 Residents’ healthcare needs are well documented within their care plans. There are no residents with pressure sores, but risk assessments are undertaken and pressure relieving mattresses and cushions are used for some residents. The Acting Manager is recommended to liaise with the Continence Promotion nurse regarding advice for residents with continence problems. At present there are no opportunities for residents to engage in light exercise and it is recommended that such sessions are provided. Care plans showed that residents’ weights are taken on a regular basis and recorded. Some residents are, however, unable to stand on scales and it is recommended that seated scales are purchased. Residents’ dietary requirements are documented, as are records of food taken on a daily basis. The NHS Chiropodist visits regularly and a private chiropodist is also available if preferred by residents. An optician and dentist visit regularly. Residents’ G.P.s review their medication on a regular basis. The home has a policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. At present there are no residents who take charge of their own medication. A thermometer has been placed in the medication room. Should the temperature exceed 25 degrees, the home must install an air cooling system in this room. The home uses a monitored dosage system. The medication is checked and signed in by two members of staff when it arrives at the home. A random sample of the cassettes and administration record sheets were seen at the inspection and there were no discrepancies. As at the last inspection, one resident had a hand-written administration record sheet, despite being at the home for over 3 weeks. All medication must be administered in conjunction with a printed medication administration record sheet, handwritten sheets only being used in exceptional circumstances. The Pharmacist must provide clearer instructions for “as required” medication. This information must include the dose, frequency and dosage interval, including the maximum daily dose. It is recommended that the home obtain a tablet cutter. None of the current residents are taking any controlled drugs, but the home has the appropriate systems in place were this to become the case. All those staff who administer medication have successfully taken part in the Safe Handling of Medicines Training. Care plans seen provided evidence that residents’ privacy is respected. One stated: “keep the door shut and curtains closed until she is ready” (following washing and dressing in the morning). The majority of rooms are single and all personal care giving takes place in private. Visitors are also able to see residents in their rooms, if they wish. A payphone is available, but the home also has a portable phone, which can be taken to individual rooms. Residents are asked when they first come to the home how they would like to be addressed. All new staff receive induction training and this includes instruction on how to treat residents with respect. There are two double rooms, which, when occupied, will be provided with screens to ensure privacy. Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Residents feel that they are able to exercise choice at the home. There has only been limited improvement in the provision of social care activities and more equipment, innovation and consultation is needed so that residents’ recreational interests are met. Relatives and friends are encouraged to maintain contact. There were some misgivings that the quality of some of the food provided (particularly the meat) may have declined. A distinct choice is not offered for the main meal and residents are not aware of alternatives available. EVIDENCE: As at the last inspection, several of the residents spoken to said that they were able to get up and go to bed when they wished. Residents’ interests and hobbies are recorded in their care plans. Although there appears to have been some improvement in the provision of activities, this has been limited and some residents, on their comment cards, indicated that there was not enough to do. An “Activities Book” is kept, but this was not up to date. A visiting singer was enjoyed and some residents went to see the Walsall Lights. Some of the staff spoken to feel that there is insufficient equipment for activities and that more should be provided. A DVD has been purchased through a staff collection and this is enjoyed. There are no notices in the home giving details of forthcoming activities. This is an area where more innovation and work is Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 13 needed. Regular meetings must take place with the residents so that their wishes and preferences can be listened to and acted upon. Relatives and friends are encouraged to maintain contact with residents after they have entered the home. This is confirmed in the new Service Users’ Guide. A Priest visits each month to administer Holy Communion. There is some involvement in the local community, but this is mostly around Christmastime, when a party is provided by Bluecoat School and another by the Rotary Club. Visits are also made to the home by carol singers and bell-ringers. Some staff feel that they would like the opportunity to take residents out locally, if only for a local walk. There is evidence that residents are able to exercise choice. Two residents request pots of tea in their rooms and this is provided, following a risk assessment. Residents may look after their own financial affairs, but none choose to do so at present. Information on the local Age Concern Advocacy Service is provided in the Service Users’ Guide. The home is recommended to inform all residents in writing of their right of access to their personal records. As at the last inspection, the residents spoken to were generally complimentary about the quality of the food provided at the home. One, however, expressed some dissatisfaction that previously popular dishes, such as lamb chops and gammon had been removed from the menu. There was some general unease that some meals had been replaced with possibly cheaper alternatives, which were not such good quality. Meatballs and turkey drummers were said not to be popular. More consultation must take place with residents about the food provided at the home. As stated at the last inspection, the menu must indicate a clear choice for the main meal, not “frozen ready meal”. A cooked breakfast is offered each day. The tea-time meal is usually sandwiches, followed by cake or fruit, but hot alternatives are available. An inspection of the kitchen showed that fridge and freezer temperatures are taken daily. The cook states that meat temperatures are also taken and this must be recorded. The kitchen was generally clean, but is now in need of refurbishment. Several cupboards do not fit properly, the cooker is original to the home and the grill is not working. Work surfaces are work and taps leak. The lunchtime meal was taken with the residents and was enjoyed. The meal was not hurried and those residents who needed assistance were given it discreetly. Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None. EVIDENCE: None of these standards were inspected on this occasion. Both Standards 16 and 18 were met at the unannounced inspection of 21st June 2005. Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26. The standards of décor within the home are improving and residents spoken to are happy with their new environment. There are still some areas outstanding which need to be addressed in order for the home to be free of hazards. The provision of a second assisted bathroom is welcomed. Residents are pleased with the improvements to individual bedrooms. Standards of cleanliness and hygiene are greatly improved. EVIDENCE: The home has undergone extensive building work during the last few months. Work is almost completed, but “finishing touches” are still underway. Residents spoken to were happy with the improvements. One said: “we now have a nice, clean place.” Another, when referring to the new lounge, said: “it’s lovely in here.” A new lounge area has been provided, along with several new bedrooms and refurbishment of older bedrooms to provide en suite facilities. When completed the home will be applying for an increase in the number of registered places, to 23. Following completion of all the work, the Registered Persons must supply to Commission with a copy of the programme of routine maintenance and renewal of the fabric of the building. There is an Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 16 attractive garden to the rear of the property and this will be made safely accessible to residents by the Spring of 2006. The front drive to the property must be renewed, as it is currently hazardous. The Acting Manager stated that all the requirements of the Fire Officer, made following his visit of 25th October 2005, have now been met. The second lounge (formerly the main lounge) is not yet in use. This is due to be decorated and provided with new furniture. Corridors are to be decorated and provided with new floor covering. It was noted that several window frames in the older part of the building are rotting and these must be replaced. Some window panes have cracks in them. Work is underway to provide an assisted bathroom on the ground floor, which will mean that there are two assisted bathrooms and one assisted shower in the home. 12 of the bedrooms will have an en suite toilet. There are separate toilets throughout the home and 2 separate sluice facilities. All new single rooms are of 12 sq. metres useable space and many of the existing rooms have been enlarged. The two double rooms are equipped with a screen. The Registered Persons state that all existing bedrooms are to be re-decorated and provided with new furniture. All bedrooms are centrally heated and the majority of radiators are covered, any not covered will be completed when the home receives its new registration. Within the new extension a new laundry has been created and this is well equipped. There are separate sluice facilities. Standards of cleanliness and hygiene within the home have greatly improved since the last inspection. Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Staffing ratios have improved since the last inspection and there are now sufficient staff to meet the needs of the residents. Good progress is being made with National Vocational Qualification training and the improved training will be of benefit to the residents. Recruitment procedures are improved, but all the required documentation must be available in the home in order to verify that the proper checks have been made. New staff receive full induction training to improve their knowledge and skills. EVIDENCE: Rotas seen at the inspection showed that during daytime shifts, 8.00 a.m. to 4.30 p.m. and 4.30 p.m. to 10.00 p.m., there are three care staff on duty. Overnight there are two waking night staff. A cleaner is employed on 7 days a week. A cook is also employed on 7 days a week, she leaves at 2.15 p.m. and the tea-time meal is served by a member of care staff. The staffing situation has improved since the last inspection and controls have been put in place to deal with occasions when staff are unable to cover their shifts. The Acting Care Manager is aware that staffing levels will need to be re-considered when the home is registered to care for 23 residents. No staff are employed under the age of 18 and there are no senior staff under 21. Residents spoke highly of the staff. One said: “They look after us very well.” Although the home has not yet achieved 50 of its care staff trained to NVQ2, excellent progress is being made and more staff have been enrolled on NVQ Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 18 training. The home is reminded that its “bank” staff also need to be NVQ qualified. Although the improvement in recruitment procedures has been maintained, there remain outstanding areas. The staff files seen at the inspection did not contain all the required documentation. The Acting Manager stated that as some members of staff had transferred from a home owned by the same company, their documentation may be with the other home. The home must ensure that all staff documentation required by this standard is available in the home. Evidence was seen from files that Criminal Records Bureau checks and POVA checks are carried out prior to a new member of staff commencing work. Copies of staff’s terms and conditions must be available in their individual files. There are good induction processes in place and records to verify this were available in the files of newly recruited staff. Staff receive at least 3 days paid training a year. Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. The Acting Care Manager has worked at the home for several years, knows the residents well and is undertaking appropriate training. It is hoped that her appointment will bring stability to the home. A programme of self-review and consultation has been introduced, although Residents’ Meetings need to be held regularly in order to ensure that residents’ views are heard and acted upon. Residents’ financial interests are safeguarded by secure systems and regular auditing. There is regular staff training and appropriate procedures are in place to safeguard the health, safety and welfare of the residents. EVIDENCE: The home currently has an Acting Manager, who has been employed at Crossways for 12 years and has held a senior position at the home for several years. She is currently undertaking the Registered Managers’ Award and the relevant units of the NVQ 4 qualification. In addition the Acting Manager has taken part in a number of relevant training courses, including the mandatory health and safety training, Adult Protection and Safe Handling of Medicines. Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 20 She is aware that she needs to receive training in Dementia Care. The home has had a period of instability as the previous Acting Care Manager left after only 2 months. A quality assurance and quality monitoring system has been introduced and the home has an annual development plan. Feedback is sought from residents and their representatives in the form of questionnaires. It was noted that no Residents’ Meetings’ meetings have been held since the end of 2004. It was clear during the visit that residents have been informed of the inspection and all those who wished to were able to speak express their views of the home. Some residents request that the home take charge of monies on their behalf. A regular audit is made of these monies and accompanying records. Receipts are kept of any purchases made on behalf of residents. The home does not act as agent for any of the residents. A check was made of a random sample of residents’ monies and accompanying records and there were no discrepancies. Staff files and training records show that staff take part in regular training in the mandatory areas of moving and handling, fire safety, first aid, food hygiene and infection control. All hazardous substances are safely secured and analyses kept of products used. Records show that fire alarm tests, emergency lighting tests and fire drills take place at the required intervals. Evidence was seen of the regular servicing and maintenance of equipment. The water is tested for legionella on a regular basis. Water temperatures at outlets accessible to residents must be checked and recorded each month. There is a written statement of the home’s policy for maintaining safe working practices in place and appropriate risk assessments have been carried out. All new staff receive induction training on safe working practice topics. Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 21 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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 X 17 X 18 X 2 3 3 X 3 3 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(1)(d) Requirement Following assessment, the Manager must write to the resident, confirming that the home will be able to meet the person’s needs. Where possible, the resident must be consulted during reviews and requested to sign the review. Printed sheets must be used to record the administration of medication (handwritten sheets can only be used in exceptional circumstances). (Previous timescale of 21/06/05 not met). The Pharmacist must be requested to provide clearer instructions for “as required” medication. This information must include the dose, frequency and dosage interval, including the maximum daily dose. Residents must be consulted about their interests and suitable activities be provided on a regular basis. (Previous timescale of 31/07/05 not met). Timescale for action 01/11/05 2 OP7 15(2)(c) 01/11/05 3 OP9 17(1)(a) Sch.3(k) 11/11/05 4 OP9 13(2) 01/11/05 5 OP12 16(2)(m) (n) 30/11/05 Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 23 6 7 8 9 10 OP15 OP15 OP15 OP15 OP19 11 12 13 OP19 OP19 OP25 14 15 16 OP28 OP29 OP38 There must be more consultation with residents about the food provided at the home. 12(2)(3) The menu must offer a distinct choice. 12(1)(a) The temperature of meats cooked for residents must be recorded. 12(1)(a) The kitchen must be refurbished and this must include the provision of a new cooker. 23(2) The home must produce a programme of routine maintenance and renewal of the fabric and decoration of the premises. Once the work to the building is completed this must be produced on an annual basis. 23(2)(o) The front drive must be renewed and made safe. 23(2)(b) Rotting window frames and cracked window panes must be renewed. 13(4) All pipework and radiators must be guarded or have guaranteed low temperature surfaces. (Previous timescale of 31/07/05 not met). 18(1) Any “bank” staff employed by the home must also take part in NVQ training. Sch 2 Staff files must contain all the Regs 7, 9, documentation required by the 19 Regulations. 13(4)(a)(c Water temperatures at outlets ) accessible to residents must be check and recorded on a monthly basis. 12(2)(3) 30/11/05 30/11/05 01/11/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 30/11/05 30/11/05 01/11/05 Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 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 3 4 5 6 7 Refer to Standard OP3 OP8 OP8 OP8 OP9 OP14 OP14 Good Practice Recommendations It is recommended that assessment information is kept within the main care plan. The Acting Manager is recommended to liaise with the Continence Promotion Nurse regarding advice for residents with continence problems. The home is recommended to provide the residents with the opportunity for light exercise sessions. The home is recommended to purchase some seated scales. The home is recommended to obtain a tablet cutter. It is recommended that there is more opportunity for staff to take residents out to locally based facilities. The home is recommended to inform all residents in writing of their right of access to their personal records. Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Crossways Residential Home DS0000020854.V252965.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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