CARE HOMES FOR OLDER PEOPLE
Croston Park Nursing Home Croston Park Nursing Home Town Road Croston Preston Lancashire PR26 9RA Lead Inspector
Val Turley Unannounced Inspection 9:00 11 and 12th May 2006
th 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 Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 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. Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Croston Park Nursing Home Address Croston Park Nursing Home Town Road Croston Preston Lancashire PR26 9RA 01772 601431 add Tel:601131 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) PCR Properties Limited Ms Grace Elizabeth McLean Care Home 46 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (45), of places Physical disability (6), Terminally ill (3) Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 5. 6. 7. Up to 25 service users in the category of OP who need personal care only. Up to 20 service users in the category of OP who need nursing care. Up to 6 service users in the category of DE(E) who need personal care only. Up to 5 service users in the category of PD aged 50 - 64 who need nursing care. 1 service user in the category of PD who needs personal care only. Up to 3 service users in the category of TI. The service should, at all times, employ a suitably qualified and experienced manager who is registered with the National Care Standards Commission. 20th January 2006 Date of last inspection Brief Description of the Service: Croston Park is a care home that provides personal and nursing care for 46 service users. The registration includes a 6-bedded unit for service users with dementia; this unit is situated separately in the upper part of the house. The home is a grade II listed building located in two acres of gardens. It is within travelling distance of Preston, Southport, Wigan and Chorley. Accommodation is provided on three floors made accessible by a passenger lift. The home has single and companion rooms some of which have an en-suite facility. Separate lounge and dining facilities are provided. The current scale of charges at the home ranges from £420 - £625. Additional charges are made for hairdressing. Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over two days in May 2006 by two regulatory inspectors. The inspection involved discussion with service users living at the home, a visiting relative and also discussion with and observation of the staff working there, an examination of records, policies and procedures and a tour of the premises. As part of the inspection, the inspectors used “case tracking” as a means of assessing some of the National Minimum Standards. This process allowed the inspectors to focus on five of the service users living at the home. All records relating to those individuals were inspected and discussion took place with the service users where possible. What the service does well:
Croston Park provides a comfortable, clean and homely environment for the service users and support staff. Service users were able to take personal possessions into the home with them to personalise their bedrooms. The service users spoken to were satisfied with the care and support provided. One of the service users spoken said she was ‘extremely pleased’ with the period of respite care she had received and ‘delighted’ by how well it had gone. She stated that the staff were ‘so kind’ and would ‘do anything they can to make you feel comfortable’. Others wrote that it was an ‘excellent home’ and that the ‘standards of food, cleanliness and care are excellent’. The relative of a service user wrote ‘The care my mother receives is second to none. Nothing is too much trouble. I am extremely pleased’. It was observed that the staff spoke to the service users sensitively and that they respected their privacy and dignity. Visitors were able to visit the home at any reasonable time and were made to feel welcome. The home had good links with health and social care professionals and they provided additional support and equipment. The home had achieved the Investors in People Award which is a quality assurance award accredited by an outside body. The manager updated policies and procedures as necessary. The staff team were well motivated and were eager to provide a relevant service. The home had a varied range of activities organised for the service users that were generally enjoyed. Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better:
The home must ensure that the support needs of the service users are thoroughly assessed and that each service user has a detailed care plan based on these assessments. This will help to ensure that there is a continuity of care provided and that this is not based solely on the knowledge that individual members of staff have of service users. This will also help to ensure that service users needs are not overlooked or neglected and show that the home demonstrates that it takes its duty of care seriously. Care must also be taken to ensure that all service users are offered drinks and snacks on a regular basis, especially during the evenings and nights. All service users or their representatives must be provided with full information about the home before admission so that they are able to make an informed decision about their choice of home. The individual interests and hobbies of service users should be acknowledged and staffing levels should enable them to pursue their interests on an individual level. The service users views of the home must be sought so that the home is able to act on any suggestions and ensure that the home is run primarily in the interests of the service users. These views must be published and made available within the statement of purpose and service user guide. All staff must receive mandatory training to ensure that the health and welfare of both the service users and the staff are protected. The older parts of the home are in need of some redecoration and refurbishment and some work needs to be undertaken to ensure that the premises were safe for both the service users and the staff. The safe storage of hazardous substances needs to be addressed to ensure that the service users did not have access to it. An Immediate Requirement Notice was issued in respect of this. The manager must also ensure that the homes systems and equipment is serviced at appropriate intervals to maintain the safety of everyone in the home.
Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 7 The deployment of staff should be examined to ensure that the home make the best use of the resources that they have for both the benefit of service users and staff. A review of the manager’s job description should be undertaken to ensure that there are clear lines of responsibility in the home. The recruitment processes in the home must be improved to ensure that the service users are protected as far as possible. The service provider and manager must act effectively on any requirements and recommendations made through the inspection process, ensuring that the home complies with legislation and adopts good working practices. Enforcement notices will be issued to the home to cover the issues relating to the formulation of care plans for each resident, pre-employment checks and evidence that the electrical installation at the home is in a satisfactory condition. 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. Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 8 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 Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 9 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): 1 and 3. Standard 6 is not applicable to this service. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service The needs of those wishing to live at the home had not been thoroughly assessed prior to admission so that the home could not be confident that the staff team could meet the individual needs of the service users safely. EVIDENCE: Although the home had a Statement of Purpose and Service User Guide in place, it contained some out of date information with regard to the way in which the service was managed. The documents also information about other services that were unconnected to the care home and as such should not be offered to prospective service users within this document. Discussions with a visitor on the day of the inspection indicated that the home does not always give this information to prospective residents and/or their representatives, which means that it makes it difficult for them make an informed decision regarding their choice of home. The files of 5 service users were examined during the course of the inspection. The information contained in the files indicated that the admission process at
Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 10 the home was generally poor. The needs of service users were not properly identified. Not enough information was collected about their health and social care needs and often assessment forms were not fully completed, signed or dated. These shortcomings made it difficult for staff to develop a detailed plan of care for service users. There was evidence on only one of the files that the service user had been involved in the assessment and care planning process. One service user who had been admitted for respite care had not had her support needs assessed before being admitted to the home. The staff at the home would therefore not have been able to decide in a structured manner whether they could meet the support needs of that service user. Not all service users had a plan of care making it impossible for care staff to provided care in a consistent way. Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 11 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The care planning processes at the home were not thorough enough or did not take place to ensure that the health and personal care needs of service users were being met consistently. Staff did however have a good individual knowledge of service users support needs and service users expressed their satisfaction with the care provided. EVIDENCE: A number of service users did not have a care plan and those that did were often poorly developed, especially were any pre-admission assessments contained limited detail. Reviews of care plans did not routinely take place and the health needs of service users were not adequately recorded within the care plans. There was little evidence that the service users were involved in the development and review of their care plans where they existed. It was then difficult to determine if the needs of service users were being fully met, although it was clear from daily record sheets that the home did seek advice and input from health professionals and that aids and equipment were
Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 12 provided and accessed appropriately. The staff had a good knowledge of the individual needs of the service users and the service users themselves were complimentary about the care and attention they received. An Enforcement Notice will be issued to the home to cover the issues relating to the formulation of care plans for each resident. Medication within the home was generally well managed with records correctly maintained. There were a number of areas were practices could have been improved to ensure further the safety and well being for the service users and some recommendations were made. The home must ensure that staff who administer medication receive accredited training and that their competency to manage and administer medication is assessed on a regular basis. It was observed that the staff spoke to the service users sensitively and that their core practice reflected the homes policies, procedures and guidance on privacy and dignity. Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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. The home works hard to ensure that service users have positive experiences during their stay at the home, although this may be limited to some degree by the poor care planning processes, the staffing arrangements and routines in the home. EVIDENCE: The staff at the home were very aware of the need to plan activities and tried to make sure that they met the choices and wishes of the service users. Activities were arranged both at the home and in the community those service users spoken to had enjoyed them. The home did not employ an activities organiser but they had sometimes had an extra member of staff on duty when activities were organised. This did not necessarily give service users the freedom to become involved in activities as and when they would like. Information regarding individual service users interests and hobbies was limited and any information collected did not form part of the care plan. Discussions with some of the service users, a visitor and members of staff indicated that visitors could visit at any reasonable time and that they were made welcome in the home. Service users were able to take personal possessions with them into the home although an inventory, to help safeguard these possessions, wasn’t always
Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 14 completed. The home made information regarding advocacy services available for any of the service users who needed assistance from an independent person who would act in their interests. Service users were able to access their personal records if they wished and information regarding this was in the Service User Guide. Information provided by the service users through questionnaires, through a survey conducted at the home and in discussion indicated that there was a general satisfaction with the food provided at the home. There was only one concern in respect of food and that was there was a possibility that for those service users who may be unable to make a specific request, there may be an interval of over twelve hours between drinks and snacks from early evening to breakfast. This could have an affect the well being of the service users. Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes policies and procedures in relation to the protection of vulnerable adults contained most of the essential information although some additional detail needed to be added to bring them into line with current good practice Some training for staff was required to ensure that staff had the skills to protect the service users as far as possible. EVIDENCE: The home had a clear complaints policy although it was recommended that it be extended to outline how the home would manage any information received through complaints, in terms of recognising any patterns or trends. Questionnaires completed by service users indicated that they knew whom they should complaint to if they were dissatisfied with the service in any way. The home should ensure that the relatives or representatives of service users are given a copy of the complaints procedure ensuring that they are able to make a complaint should they wish to do so. The home had a policy in place that dealt with the protection of vulnerable adults. This needed some minor amendments to bring it into line with current guidance and to ensure that any concerns regarding the safety and well being of service users is dealt with efficiently and effectively. Some of the staff at the home had received training in this area, but the home must extend this to ensure all staff receives training. The homes policy dealing with the management of challenging behaviour was clear but did state that staff would
Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 16 receive training in this although there was no evidence that this training had taken place. As the home did not have adequate assessments or care plans in place for all of the service users there was a possibility that their needs were not being met through the negligence of the home. Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was essentially clean, comfortable and homely although there was some outstanding work to be undertaken to ensure that the home remained in a good state of repair and redecoration and provided a safe environment for the service users. EVIDENCE: The home was clean, comfortable and homely. Both service users and visitors were happy with this aspect of the home. Generally rooms were decorated and repairs were attended to as needed although the older part of the home was in need of some redecoration. Some of the windows in the older part of the house were propped open inappropriately and as such placed the service users at some risk if they had tried to open or close the windows themselves. The grounds were well-maintained and attractive providing service users with an enjoyable outdoor space. The laundry at the home was well equipped and was clean and well maintained. The home had good policies in place regarding infection control
Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 18 and protective clothing was in place for staff to use to help prevent the spread of any infection. Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The homes recruitment procedures did not protect service users, as the relevant checks were not always undertaken before staff commenced work. Staff did not receive training in the basic mandatory courses and were therefore not equipped with the necessary skills required in their role. EVIDENCE: The service users spoken to had confidence in the staff who cared for them although there were occasions when there was no one to help service users immediately. Generally the staff team felt that there were enough staff on duty to meet peoples needs although did feel under pressure at times if for instance a member of staff was not in or if a service user was ill. The staff team was very reliable and there was very little use of agency staff, which ensured as far as possible a continuity of care for the service users. Recruitment procedures in the home had improved greatly since the last inspection however the file of a recently appointed member of staff indicated that the home was still not thorough enough in its approach and this left service users unprotected. The home must ensure that all checks and references for new members are in place prior to the start of employment. An Enforcement Notice will be issued to the home to cover the issue of preemployment checks. The home had a poor training record and must ensure that staff receive mandatory training in the relevant areas to ensure as far as possible the safety and well-being of both the service user and themselves and that this training is
Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 20 renewed at appropriate intervals. Records did indicate that new staff received induction training and that the home did encourage staff to work towards a nationally recognised qualification although because of recent staff changes, less than 50 of the staff team had achieved this. Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is inconsistent. And the registered manager does not properly develop quality assurance systems. EVIDENCE: The registered manager was a qualified nurse who had also achieved an NVQ level 4 and the Registered Managers Award. Recent changes in the way the home was managed on a day-to-day basis, with senior staff being given additional responsibilities, had resulted in a situation where the manager and the administration manager did not have clear job descriptions. This had resulted in staff not always being clear as to the lines of accountability within the home leading to some confusion amongst the staff. A review of the manager’s job description may help to resolve some of these difficulties. The manager had not ensured that all requirements and recommendations made at previous inspections had been acted upon.
Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 22 The home had some quality monitoring systems in place. The manager had reviewed policies and procedures recently to ensure as far as possible that they contained up to date information. The home had achieved an Investors in People Award which is a quality assurance award accredited by an external body. An internal survey had been undertaken asking service users if they were happy with the food that the home provided. The home had not undertake a survey of service users views of the home and made these available to prospective service users. Other surveys should also be undertaken to ensure that the families, friends and involved health and social care professionals are satisfied with the care that the home provides. The home held only small amounts of money on behalf of service users and a record was kept of any transactions made on their behalf. The home had secure facilities for the safekeeping of any money or valuables on behalf of the service user. The home had a considerable amount of work to undertake to ensure as far as possible the health, safety and well being of the staff. All care and domestic staff must complete mandatory training and the training records should be amended to make it clear what level of qualification has been achieved in first aid. There were a number of areas in the home where cleaning fluids and other hazardous substance had been left in areas that the service users could access leaving them in a position of risk. An Immediate Requirement Notice was issued in respect of this. The homes electrical system did not have a valid certificate. This was an issue identified at the previous inspection, which had not been addressed satisfactorily. An Enforcement Notice will be issued requiring evidence that the electrical installation at the home is in a satisfactory condition. The home had achieved some improvements since the last inspection. A number coded lock had been fitted to the front door of the home, improving the security of the home and safeguarding both service users and staff. The accident report forms had been filed appropriately on service users files enabling any patterns or trends in respect of those individuals to be identified. Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 X 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 1 Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4,5 Schedule 1 5(2) 14(1) Requirement The Statement of Purpose and Service User Guide must reflect the services that the home is registered to offer. A Service User Guide should be provided for all service users and/or their representative The registered persons must ensure that a suitably trained person has assessed the needs of prospective service users prior to their admission. (Timescale of 28/02/06 not met.) All service users must be provided with a written plan of care. (Timescale of 31/01/06 not met) Service users plans must be kept under review. (Timescale of 31/03/06 not met.) Wherever possible care plans must be drawn up in conjunction with the service users and/or their representative. (Timescale
DS0000025537.V290245.R01.S.doc Timescale for action 30/06/06 2 3. OP1 OP3 30/06/06 31/05/06 4. OP7 15(1) 21/06/06 5. OP7 15(2)(c) 30/06/06 6. OP7 15(2)(c) 30/06/06 Croston Park Nursing Home Version 5.1 Page 25 of 31/03/06 not met). 7 8. OP9 OP12 13(2) 16(2)(m) Staff must receive accredited training in the administration of medication. Service users must be consulted about their social interests and make arrangements for them to follow these. (Timescale of 31/03/06 not met) A record must be kept of furniture that the service user brings into the home with them. The registered manager must ensure that the dietary requirements of service users are considered and attended to. (Timescale of 28/02/06 not met) The registered person must ensure that all service users or their representative is given information regarding the homes complaints procedure. The homes policy dealing with the protection of vulnerable adults must be amended to incorporate current guidance. All parts of the home must be kept reasonably well decorated. Windows must be repaired to ensure that unnecessary risks to service users are eliminated. The registered person must not employ a person to work at the home unless the necessary checks have been made. (Timescale of 28/02/06 not met) 31/08/06 30/06/06 9 10. OP14 OP15 Schedule 4 16(2)(i) 30/06/06 31/05/06 11 OP16 5(1)(2) 30/06/06 12 OP18 13(6) 30/06/06 13. 14 15. OP19 OP19 OP29 23(2)(d) 13(4) 19 31/12/06 30/06/06 21/06/06 16 OP30 18 The registered person must 30/09/06 ensure that persons employed at the home receive training appropriate to the work that they are to perform and clear records must be kept of this training
DS0000025537.V290245.R01.S.doc Version 5.1 Page 26 Croston Park Nursing Home 17. OP33 24(3) Consultation must take place with the service users with a view to improving the service provided. 30/09/06 18. OP33 26 The registered provider must 30/06/06 undertake at least monthlyunannounced monitoring visits to the home and supply a copy of the report to the Commission for Social Care Inspection. (Timescale of 31/03/06 not met) The electrical systems at the home must be maintained. Hazardous substances must be stored appropriately to reduce any unnecessary risks to the health or safety of the service users. 07/07/06 15/05/06 19. 20 OP38 OP38 13(4)(c) 13(4) 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 OP7 OP9 OP9 OP9 OP9 OP9 OP15 Good Practice Recommendations Care plans should be reviewed on at least a monthly basis. Any handwritten entries on the Medication Administration Records should be witnessed and countersigned. Risk assessments should be in place for any service user administering external preparations. A record should be kept of any medications that are administered by service users. Competency checks should be undertaken on all staff administering medication and a record kept of these. An audit of the homes management of medication should be undertaken regularly. The interval between snacks and meals should be no more than twelve hours.
DS0000025537.V290245.R01.S.doc Version 5.1 Page 27 Croston Park Nursing Home 8 9 10 11 OP16 OP18 OP28 OP30 The complaints procedure should be extended to make it clear that the home will manage information received through complaints. Training should be provided in the management of challenging behaviour. The home should work towards having 50 of its staff achieve a nationally recognised qualification. The manager should develop a staff training and development programme, which fulfils the aims of the home and meets the needs of the service users. The manager’s job description should be reviewed to reflect the responsibilities of the post. The views of relatives and health and social care professionals should be sought as part of the homes quality assurance audits. 12 13 OP31 OP33 Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Croston Park Nursing Home DS0000025537.V290245.R01.S.doc Version 5.1 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
