CARE HOME ADULTS 18-65
Croft (The) Buckland Road Reigate Heath Surrey RH2 9JP Lead Inspector
Pat Collins Announced 10 & 26 May 2005
th 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Croft (The) Address Buckland Road, Reigate Heath, Surrey. RH2 9JP 01737 246964 01737 246964 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Heddmara Limited Michele Anne Waddington Care Home 22 Category(ies) of Learning Disability (16) registration, with number Learning Disability over 65 (6) of places Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: The age range of those accommodated within the category LD will be 18-64 Years. The age range of those accommodated within the category LD(E) will be 65 years and over. Date of last inspection 7 October 2004 Brief Description of the Service: The Croft is a care home providing accommodation and personal care for 16 adults with learning disabilities aged from 51 years and 6 older people with learning disabilities aged from 65 years. Service provision is for men and women. The Croft is a large detached home situated a short distance from Reigate town centre.Accommodation is provided on three floors with lift access to the first and second floors. The home has a large lounge area and a separate dining room. Service users have access to a patio garden and a large rear garden. The home has car-parking facilities to the front and side of the property.A day centre is located within the grounds of the home and is accessed by service users as well as by people from outside the home. The day centre operates independently from the residential service provided at The Croft. Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection was carried out by one inspector over two visits. The process included discussions with some residents, management and members of staff. Comment cards returned from residents, relatives and professionals involved with the home were reviewed and various issues arising from these followed up. The premises were inspected and records examined. The inspection report refers to the people who live at The Croft as ‘residents’ in accordance with the wishes of individuals interviewed. The inspector would like to take this opportunity of thanking the residents for their courtesy in showing the inspector around their home. Also to the manager and her team for their courtesy and cooperation. What the service does well: What has improved since the last inspection?
The building work in a new two - storey extension was nearing completion. The new facilities will enhance the quality of resident’s lives. This will be achieved by increased provision of single bedrooms and more space in communal areas. The upgrading programme had included redecoration and refurbishment of the existing accommodation to a good standard, affording a more ‘homely’ and
Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 6 comfortable environment. There had been significant improvement in health and safety matters. Building debris had been removed and safety barriers were in place cordoning off areas of risk. Work had been completed for compliance with fire safety requirements. Provision of a disabled platform lift had improved accessibility of first and second floor accommodation for residents with reduced mobility. Feedback from health care professionals was mostly positive confirming improvement in communication since the manager’s appointment. Door alarms had been fitted to external doors for the purpose of meeting the needs of one resident. Relatives expressed gratitude to the staff and felt secure in the knowledge of the staff teams competencies and kindness. 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. Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2,3, 4 and 5. The home had good quality information available to enable an informed decision about moving in. Assessment and admission procedures were satisfactory and residents had contracts. EVIDENCE: The home had a detailed Statement of Purpose document. Also an information booklet (Service Users Guide) using photographs and widget symbols. This information was available to prospective residents and their representatives to enable an informed choice about the choice of home. Residents had a personal copy of the Service Users Guide in their rooms, also photographs and information about their key workers. They each had a terms and conditions of residency document in a ‘user friendly’ format on file. In their rooms they had information about the role of inspectors and copy of the complaint procedure in widget form. All residents were funded by Care Management and admitted on the basis of a full assessment of needs. The admission procedures included a trial period. Staff demonstrated good understanding of residents needs and were skilled in signing and use of other modes of communication. Most residents had lived at the home since its registration in 1991. The needs and dependency of some had increased due to ageing. The organisation had invested in the premises, staff resources and equipment in response. A number of residents were in need of some one to one staff time. Two residents required two staff to meet personal care needs. Contracts for individuals were understood to have been renegotiated since admission and agreements in place for additional funding to provide some one to one care. The manager
Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 9 however did not know which residents were funded for one to one care and was advised to obtain this information to ensure contractual obligations were being met in the allocation of staff’s time. Negotiations were continuing with two Local Authorities for additional funding in response to an increase in dependency. Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7,8, 9 The operation of the home ensured the needs of residents were mostly met through existing staff resources. Staff strived to meet residents’ needs, goals and aspirations with some difficultly at times due to the size of the group and increasing dependency levels. Residents were involved in some aspects of the running of their home and staff working towards their fuller involvement within individual capabilities. Residents were supported in informed risk taking. EVIDENCE: The residents each had a care plan which comprehensively covered all aspects of their needs. The manager stated that these had been drawn up in consultation with residents. Those sampled demonstrated that needs were being met and risks assessed and addressed by clear care plans. Risks were managed at the time of the inspection by various methods including delegated responsibility for observing one resident at all times when door alarms fitted to safeguard this person were deactivated for operational reasons. Also instruction to night staff to ensure adequate 24 hour observation of this person. The care plan formats had been revised by the manager and were considered comprehensive. Discussions included areas where these could be further developed and designed in a format more accessible to residents.
Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 11 Observations throughout the inspection and from records demonstrated residents’ rights for decision making were respected and where limited, this was decided through assessment processes. Residents had some one to one time with key workers each week used to meet needs, to go shopping for personal items and for leisure activities in the home and in the community. Most of the residents gave feedback that they were not involved in shopping and cooking though staff stated that some were. The inspector was informed by a staff member that discussions were taking place within the team on future plans that will increase opportunities for resident’s to participate in domestic routines under supervision. Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14 and 16 Residents were being enabled to lead fulfilling lifestyles in and outside of the home. They were supported in engaging in appropriate leisure activities and use of community facilities and resources. The rights of residents were respected and recognised by staff in the daily operation of the home and visitors were made welcome. EVIDENCE: Staff provided support and encouragement to residents enabling them to make decisions and choices in their daily lives. There was evidence that residents participated in fulfilling activities both inside and outside of the home. Each had a weekly timetable of activities. Individuals attended day placements during the week where they had opportunity to form friendships outside of the home. Staff members were observed accompanying several residents to town to undertake personal shopping. Staff were flexible in their shift patterns to ensure provision of support to residents involved in activities outside the home in the evenings and at weekends. Holidays for groups and individuals were arranged with staff support also a variety of outings. Residents were consulted and able to express choices. Visitors were welcome though most residents had
Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 13 minimal contact with relatives and few had visitors. Relatives and visitors who responded to the Commission in comment cards were satisfied with standards of care and levels of communication and consultation with them. It was confirmed that they were made welcome by staff when they visited and they could speak with the person they were visiting in private. The daily routines and house rules were observed to promote independence, individual choice and freedom of movement, subject to restrictions agreed in care plans. Arrangements were in place for each resident to have weekly one to one time with their key-workers. There was recognition of the need to provide additional one to one staff time for individuals to meet needs but pressures on staff time could be a constraint at times. Also the need for increased support to further engage residents in domestic routines. Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 21 Personal and healthcare support was provided to meet physical and social needs with due regard to residents’ privacy and dignity, promoting independence and control over their daily lives within individual capabilities. The continuing increasing dependency of individuals can at times detract from the time available to spend with others whose physical needs are not as high. Ageing, illness and death of a resident are handled with sensitivity and involve all relevant parties. EVIDENCE: Residents were registered with General Practitioners (GP’s) and feedback from GP’s confirmed there was always a senior member of staff to confer with. They expressed satisfaction with arrangements for communication which it was stated had improved under the new manager. Arrangements were satisfactory for chiropody, dental and ophthalmic care. Physiotherapy and speech and language therapy was provided based on individual needs assessments. Staff had delegated responsibilities for ensuring programmes and instructions of therapists were followed. It was agreed with the manager this area of care should be reviewed to ensure all staff were fully familiar with these programmes and records maintained by staff with this delegated responsibility to daily substantiate these programmes were carried out. District Nurses were noted to have responsibility for the management of the catheter care for one resident. The staff team had received instruction in this area of care and on
Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 15 infection control procedures. Protective gloves and aprons were provided. A care plan was in place supported by staff training for administration of food through a PEG tube for a resident. There was evidence of input to the care plan of this individual by a dietician. Discussions with the manager included areas for developing risk assessments for the safe use of bedrails. Also for records to include evidence of explicit assessment using a recognised tool for identifying risk of developing pressure sores. Care plans contained copies of the procedure to follow in the management of ageing, dying and death. Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 Policies and practices were robust for responding to suspicions and evidence of abuse. Improvement is required however to vetting procedures in the recruitment of new staff to ensure adequate safeguards for the protection of vulnerable adults. EVIDENCE: The home had an internal abuse procedure which appropriately integrated with Surrey’s multi-agency vulnerable adult protection procedures. Requirement was made for the home to have a revised copy of Surrey’s procedures. These procedures had been invoked by Care Management in November 2004 for review of incidents specific to the behaviour of a resident and impact of these on the welfare of others. Systems were in place for the protection of residents from financial abuse. Residents were allocated a lockable cash box and detailed records were maintained of income and expenditure, which were audited by two members of staff on a monthly basis. It was recommended that external auditing arrangements be considered. There was an ongoing programme of vulnerable adult protection training for staff. The home’s records demonstrated the team had been shown a training video on this subject. Attention was drawn to changes in recruitment practices implemented on 26th July 2004 associated with Criminal Record Bureau Disclosures for staff and requirements made for compliance to ensure adequate safeguards for the protection of residents. Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 17 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30. The upgrading and refurbishment programme was ongoing to ensure the suitability of the environment to continue to meet the changing needs of residents. Other improvements were identified to be necessary. EVIDENCE: The inspector toured the premises and found all areas to be clean and the décor was of a good standard. The refurbishment programme had replaced furniture and made provision of comfortable seating. Provision included some environmental adaptations and equipment necessary to meet needs. Bedrooms were personalised reflecting the tastes and interests of residents. There was an ongoing programme for fitting privacy locks to bedroom doors. The work programme for the new extension was nearing completion. On completion of the new extension most residents will have single bedrooms. Whilst bathrooms, toilets and shower room afforded privacy these facilities in the original building required upgrading. Communal space had been extended and was suitable to meet needs. Discussion took place with management regarding outstanding documentation necessary to be able to conclude processing the application for variation of the home’s conditions of registration and enable occupation of new bedroom accommodation.
Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 18 The windows in some bedrooms in the new extension were small and natural lighting limited. However this was unlikely to adversely impact on the quality of life of those occupying these rooms on the basis that residents spend much of their time during the day in communal areas and out of the home. The new extension had not fully met National Minimum Standards in that bedrooms did not have en-suite facilities. Requirement was not made for this provision on the basis that they were within close proximity of bathrooms and toilets. The need to upgrade the ground floor shower room was discussed also for bathrooms to be upgraded. The extractor fans in toilets and bathrooms required review to ensure these were adequate and floor coverings replaced. Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 19 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 35 and 36 There was clarity of staff roles and responsibilities and a training programme to ensure staff competencies. The need for further review of staffing levels was identified. Areas of staff recruitment and vetting procedures required attention. Residents benefited from a supported and supervised staff team. EVIDENCE: Staff demonstrated understanding of their role and the purpose of the home. They had clear job descriptions and access to an appraisal system to review performance and agree career development plans. They also received formal and informal supervised support for monitoring work, identifying training needs and provision of support. There was a formal induction programme for new staff. The need to ensure induction booklets were fully completed was discussed. Also for new staff to have an allocated staff mentor for the first four weeks of their employment who should be on duty at the same time where practicable. Compliance was required with the statutory requirement for staff recruitment procedures pending Criminal Records Bureau (CRB) Disclosures for staff and where staff are urgently required, POVAFirst checks. Attention was drawn to related changes specific to CRB Disclosures and that these were non-transferable since 26th July 2004 on the implementation of the Protection of Vulnerable Adults Scheme. The need for formal recorded risk assessments to be in place in
Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 20 support of some recruitment decisions was discussed. Attention was drawn to required improvements in recording, storage and disposal of CRB Disclosures. The manager had increased staffing levels since her appointment from 4 support workers to 5 on day duty and on night duty to provide 2 waking support workers and one on –call, sleeping on the premises. Whilst it was acknowledged that staff were working hard to try to meet residents needs, the increasing levels of dependency in which six residents required daily one to one support and individuals’ required two staff for provision of some personal care inevitably detracted from the available care hours shared between other residents. The manager had been informed that some residents were being funded for additional care hours but did not have a record of who these residents were and how many additional hours each was funded. Requirements include the need to establish this information and review staffing levels taking into accounted contracted additional hours and dependency levels, using the nationally recognised staffing tool. Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 41 and 42. The management of the home was competent with lines of accountability clearly defined. The manager ensured the welfare of residents and provided adequate direction and leadership to staff. There was evidence of good team working to the benefit of residents’. Records were organised and maintained up to date. Arrangements for ensuring residents safety required further attention. EVIDENCE: Since the last inspection the home manager had been registered with the Commission for Social Care Inspection. The manager was suitably qualified including having the Registered Managers Award qualification. The Commission awaited written confirmation from the organisation of a change in the Responsible Individual. The manager was in receipt of good support from the organisation and consultancy contracted to undertake monthly inspection visits on behalf of the organisation. A copy of this report was received monthly by the Commission.
Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 22 Positive comments were received from relatives and professionals in feedback comment cards about improvements in the home’s management since the appointment of the current manager. Observations confirmed efficient and effective management systems and residents benefiting from a positive and inclusive management approach. Relationships between senior staff appeared professional and harmonious and the atmosphere of the home was warm and friendly. The records sampled were mostly up to date and well organised. The manager assured the inspector these were maintained secure through the practice of locking the office door when the office was not in use. Discussed with the manager was the scope of reporting significant events to the Commission, noting a failure to report a recent incident. Some environmental risks were evident at the time of the inspection and risk assessments were carried out. An action plan was required for fitting radiator covers to radiators that were not of the low surface temperature type. Valves must be fitted for the regulation of hot water temperatures to two baths. The doorstop in a corridor in the new extension was a trip hazard and a requirement was made. Staff were in the process of fencing off and levelling grounds at the front of the home for provision of a safe garden area for residents’ use. Work was planned for a ramp with handrails to be fitted from the fire exit in the lounge in the new extension leading to a terrace area which was part constructed. Requirements included provision of timescales for completion of this work. Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 4 3 3 3 3 Standard No 22 23
ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 2 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 2 2 2 3 2 3 Standard No 11 12 13 14 15 16 17 2 4 3 4 x 2 x Standard No 31 32 33 34 35 36 Score 3 3 2 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Croft (The) Score 3 2 x 3 Standard No 37 38 39 40 41 42 43 Score 3 3 x x 2 x x H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 24 Yes 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 1,3,6 Regulation 15(2)(a) Requirement Timescale for action 26/08/05 2. 3,5,33 18(1)(a) 3. 8,11,16 12(1)(b) 4. 19 13(4)(a) (b)(c) For the registered person to develop care plans in a format that can be understoof by residents. Whilst overall the content of care plans reflected the needs of residents a small number required additional information. 26/06/05 For the registered person to review the homes staffing levels taking into account needs and dependency levels, contractual obligations for additional care hours and day placement hours using the Residential Forum staffing tool and for the outcome and record of the review methodology to be forwarded to the Commission. For the registered person to 26/08/05 ensure residents to have sufficient opportunity within individual capabilities and preferences to participate in life skills and domestic skills activities in the operation of their home. For the registered person to 26/06/05 further develop risk assessments for use of bedrails and prevention of pressure sores.
Version 1.30 Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Page 25 5. 23 13(6) 6. 23, 34 19(4) 7. 24, 42 13(4)(a) (b)(c) 8. 24, 42 13(4)(a) (b)(c) 9. 24, 27 13(5) 23(2)(b) For the registered person to obtain a revised copy of Surreys multi-agency adult protection procedures. For the registered person to ensure that staff recruitment procedures adhere to requirements for new staff to have CRB Disclosures and POVA checks carried out. In exceptional circumstances new staff may take up post on the basis of a POVAFirst check and work under direct supervision until receipt of a full CRB Disclosure. Staff employed since 26/07/04 on the basis of a CRB Disclosure from a former employer must reapply for CRB Disclosures including a POVA first check. For the registered person to develop an action plan with timescales for fitting radiator covers throughout the home, commencing with areas of highest risk and forward this to the commission. For the registered person to fit safety valves to the remaining two baths for control of hot water at the point of delivery at a safe temperature of near 43 degree centigrate. In the interim for robust procedures to be in place to ensure residents do not have unsupervised access to these bathrooms. For the registered person to assess existing bathrooms, shower rooms and toilets to ensure their suitability for meeting needs and for safe moving and handling practices. Ventilation in these areas requires improvement and a programme of replacing floor coverings instituted. An action 26/06/05 02/06/05 26/07/05 26/08/05 26/07/05 Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 26 10. 25 11. 26 12. 34 13. 35 14. 37 15. 37 16. 41 plan for improvement is required by the Commission. Timecale unmet from the last inspection 23(1) For the registered person to ensure service users have made a positive choice in sharing bedrooms. 12(4)23 For the registered person to (2)(e) ensure completion of the programme for fitting safety locks to bedroom doors. Timescale for fitting them in the new extension unmet from the last inspection. 19(1) For the registered person to review the homes recruitment procedures to ensure sufficient information is obtained of prospective employees employment history and a record made of explanations received for gaps in employment and other relevant information to justify recruitment decisions. Risk assessments should be completed as necessary to underpin particular recruitment decisions. 18(1)(i)(2 For the registered person to )(a)(i)(ii) ensure staff induction records are fully completed and mentoring arrangements to be in accordance with statutory requirements. 7(2)©(i) For the registered person to (ii) provide written confirmation to the Commission of the organisations named Responsible Individual. 10(1) For the Registered Person to ensure variation is sought to the homes conditions of registration to reflect the current needs of residents. 19(1)Sch2 For the registered person to ensure that the recording, storage and disposal of CRB Disclosures be in accordance
H58H09 S13619 The Croft V221878 100505 stage 4.doc 26/08/05 26/08/05 26/06/05 26/06/05 26/06/05 26/06/05 26/06/05 Croft (The) Version 1.30 Page 27 with CRB policy. 17. 41 23(1)(2) For the registered person to ensure notification of all significant occurrences to the Commission within the scope of guidance available from the Commission. For the registered person to produce an action plan with timescales to be developed and supplied to the Commission for provision of a ramp with handrails from the fire exit in the new lounge. Also for completion of work for provison of a safe terraced area at the front of the home. 26/06/05 18. 42 12(1), 13(4) 23(1)(2) (4) 26/06/05 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. Refer to Standard Good Practice Recommendations Croft (The) H58H09 S13619 The Croft V221878 100505 stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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