Inspection on 24/10/05 for The Croft

This inspection was carried out on 24th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Croft 23/05/07

The Croft 22/08/06

The Croft 25/10/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Croft Chestnut Lane Amersham Bucks HP6 6EJ Lead Inspector Gill Wooldridge Unannounced Inspection 24th October 2005 13:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Croft DS0000023060.V261336.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. The Croft DS0000023060.V261336.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Croft Address Chestnut Lane Amersham Bucks HP6 6EJ 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) 01494 732500 01494 732 510 Heritage Care Care Home 60 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0), Physical disability (0) of places The Croft DS0000023060.V261336.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 60 older people, some of whom may have dementia and/or physical disabilities 9th May 2005 Date of last inspection Brief Description of the Service: The Croft is a residential home providing accommodation for sixty elderly residents in the catorgories of old age and dementia. The accommodation is over two floors and access to the first floor is via a shaft lift, or stairs. The home has sixty single bedrooms all having en-suite facilities. The communal areas are well situated on the ground and first floor floor. The layout of the home is condusive to meeting the needs of residents. The home is divided into four units supporting half the residents in the catergory of dementia care. The home is situated in Amersham, a small market town close to all local amenities. The home has good road links to other larger towns, it is also served by public transport. The Croft DS0000023060.V261336.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place on 24th October at 1pm until 5.30 pm. The inspection was carried out by the lead inspector. During the course of the inspection the requirements and recommendations from the last inspection were discussed and some evidence was found to ensure that requirements and good practice recommendations had been followed through. During a tour of the building most of the bedrooms were viewed, mostly from the corridors and some bedrooms were entered with residents permission. Two care plans were studied and the care of a further two residents was tracked. Training records and Medication Administration Record (MAR) sheets were also studied as were some policies/ protocols. Several staff on duty were spoken to and their practice observed. Time was spent with the manager, deputy manager and a senior manager. Time was spent in conversation with residents during the tour of the building and relatives spoken with. Interactions between staff and residents were also observed including activities. What the service does well: The home maintains residents’ independence and encourages residents to continue to live the lifestyle that they would in their own homes. Staff meet residents’ needs and use care plans and the level of care is good. Residents were well presented with appropriate attire, clean finger nails and their own jewellery. Activities are supported by an activity organiser who supports residents and staff so there is a continuous programme of activities. Staff facilitate further activities. The home is warm, friendly and welcoming. Families feel at ease and there is an open door policy to facilitate this. The home has an established staff team which supports new staff. The home invites an advocacy agency to support residents. Residents influence decisions made in the home through residents meetings. The senior team is approachable and staff receive regular supervision. Overall there is good liaison with health professionals. The Croft DS0000023060.V261336.R01.S.doc Version 5.0 Page 6 The home provides a modern environment which meets residents’ needs. The home ensures that during an assessment the staff member allocated provides continuity and is on duty when the resident is admitted to the home What has improved since the last inspection? The care planning process has been developed and shows some marked improvement in those care plans seen. Care plans are more reflective of the presenting needs of residents and generally ensure that identified issues are followed through. Protocols for diabetes, stoma care and other medical conditions have been developed since the last inspection. A new format regarding the daily log has encouraged staff to more clearly record the pertinent points of the residents day. Bathing records have improved and residents are weighed regularly. Risk assessments have improved in detail and are supported by the falls clinics assessment. The manager and senior team have developed monitoring system for the lunch time period to monitor staff performance and ascertain the meals liked by residents. Staff performance during this time has been monitored. However, records must be maintained for inspection purposes. Staff deployment was more appropriate than at the previous inspection. The deployment of agency staff has been reviewed and must be further reviewed regarding agency staff training. The odour in room 25 has been eliminated. Pedal bins have been purchased to aid infection control. Steradant tablets and latex gloves were stored appropriately. The Croft DS0000023060.V261336.R01.S.doc Version 5.0 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Croft DS0000023060.V261336.R01.S.doc Version 5.0 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 The Croft DS0000023060.V261336.R01.S.doc Version 5.0 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): 3 Assessment information must be detailed to enable staff to refer to the information and satisfactorily meet residents’ needs. EVIDENCE: Staff described clearly the process of the last admission to the home. However, this was not clearly documented. The process of assessment was discussed with staff and the deputy manager and it is evident that the organisation’s procedures are not being fully followed. It is of concern that this written information did not meet the Standard. It is also of concern that information that is not clearly documented may get lost in the exchange of verbal information. Staff must be supported and trained to assess prospective residents and supported by good practice guidelines to ensure that the home makes the decision as to whether or not it can meet this resident’s needs. The Croft DS0000023060.V261336.R01.S.doc Version 5.0 Page 10 The manager must ensure that future admissions are supported by a completed assessment of need. Staff training and procedures along with an audit system must be developed to support the process. (Previous timescale of 31/6/05 not met). The proprietor and manager must explain in writing to the Commission why this requirement has not been met within two weeks of receipt of this report. Since the last inspection the deputy manager has developed a format for staff to follow regarding assessments. It was not evident that staff were using or following this system. The format includes ‘name by which you would like to be known.’ This is acknowledged as good practice. The resident had not signed the document. The information contained included information gained from the referring authority and the only additional information was the resident’s medication. It was not clear that this resident was receiving a respite service. It is strongly recommended that the manager develop clear protocols to support staff’s described practice with regard to emergency and respite admissions and that this is reiterated to staff. The Croft DS0000023060.V261336.R01.S.doc Version 5.0 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 The detail contained in the care plans, if referred to, should ensure that residents’ personal health and social needs are met. There is more detail contained in risk assessments, this should ensure that risks are kept to a minimum. There are some weaknesses in the medication procedure identified in the body of the report, which have the potential to place residents at risk. EVIDENCE: It was evident that the detail and content of the care plans viewed had improved considerably since the last inspection. Residents’ care plans were viewed either as identified by the manager or by tracking at random residents care. At the previous inspection the manager was required to develop care plans to ensure they met the Standard. It was evident that the management team have worked to ensure the Standard is met. The Croft DS0000023060.V261336.R01.S.doc Version 5.0 Page 12 Likes and dislikes were clearly recorded and bathing rosters showed that residents had regular baths as identified in their individual care plans. The care plans detailed emotional support and the entry referred to the resident’s wife and family relationships. Care plans relating to communication detailed ‘X is a little deaf- staff will need to speak a little louder and clearly’. An entry regarding a resident’s mobility included an entry for example ‘X mobility varies greatly on a day to day basis due to his illness’. Dignity and privacy and independence were also detailed as part of this care plan which included ‘likes to look smart and always has a hankie tucked into his shirt pocket’ a further entry detailed ‘has his 7.00 am medication by day staff and remains in bed for half an hour for his tablets to work. Care plans referred to daily activities and at least two care plans detailed that the residents preferred the Daily Telegraph or Daily Express. A further resident described receiving a magazine relating to his favourite sport ‘Speedway’. Residents’ religion or faith was also clearly recorded. Care plans emphasised that the resident had been involved in the process for example ‘I can dress myself independently but need help with my buttons’. The assessment viewed as described earlier did have some detail in the care plan however this focused on the resident’s personal care. This document must be developed within two weeks of this report to cover the resident’s social and recreational needs. Missing person documents were on the whole completed. Residents weights were recorded, generally monthly. Whilst tracking one residents care it was apparent that the staff monitor this resident’s weight more frequently. The weights and care plans need to interrelate more fully and advice must be sought from the dietician if significant weight loss is recorded. The deputy manager described that the senior team would refer to a range of health professionals as appropriate. It is strongly recommended that the manager develop a health intervention sheet to aid in following through residents care. Risk assessments have shown some improvement and more detail was generally recorded in those seen. The home is supported by the falls clinic which support the home through a further risk assessment, this is noted as good practice. However, it is strongly recommended that the manager conduct an audit of falls to establish if there are any patterns or trends. Staff were observed to interact with residents in a positive way promoting choice. Residents described staff in such terms as ’kind and supportive’. The Croft DS0000023060.V261336.R01.S.doc Version 5.0 Page 13 Interactions observed between staff and residents were good humoured and respectful. Those residents who were limited in their communication skills appeared to express their satisfaction with their home through their body language. In the dementia unit, residents who were up and dressed looked well cared for with attention to detail such as clean finger nails and coordinated clothing. Music was playing in this unit with residents appearing to enjoy this and the views of the garden. Medication Administration Records (MAR) sheets were studied and on one MAR sheet there was a gap, on a further MAR sheet staff had written over an entry. Staff were not consistent in their use of codes and only a small number of staff were using the back of the MAR sheet to clarify the use of codes. For at least two residents it was evident that their medication had not been available for staff to administer. This is of concern. The manager confirmed she had been in discussions with the pharmacy regarding these issues. All staff who are responsible for recording, handling, safekeeping, safe administration and disposal of medicines must be assessed as competent. The manager must maintain staff competency records in the home. The manager must continue to audit the home’s (MAR) sheets. Staff had hand written entries on the MAR sheets although these had been signed by two staff, this is acknowledged as good practice. Evidence was seen that supported staff’s practice relating to the covert administration of medication and the home’s policy is clear. This document must be dated and reviewed on a regular basis. The managers have developed a clear information folder relating to best practice regarding stoma care and diabetes, this is acknowledged as good practice although these documents should be duplicated in care plans where appropriate. The Croft DS0000023060.V261336.R01.S.doc Version 5.0 Page 14 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): 13 & 14 The home facilitates an advocacy agency which should ensure that residents are helped to exercise choice and control over their lives. EVIDENCE: Care plans viewed indicated that residents and relatives, where appropriate, are involved in residents care plans. From receipt of service users comment cards to the question ‘do you like the food’ a number of residents replied ‘sometimes’. Discussions with residents regarding the meal process have indicated some changes to facilitate further choice and liaison with the kitchen staff has facilitated some changes. It is recommended that the manager continues to monitor the meal time process and produces an action plan following her research. The deputy manager confirmed that an advocacy agency holds regular meetings with residents which should ensure that residents are encouraged to raise issues that effect their lives. The Croft DS0000023060.V261336.R01.S.doc Version 5.0 Page 15 The open management style and friendliness should ensure that issues are raised and actioned. Relatives spoken to during the inspection, who visit the home daily, indicated that the staffing levels were satisfactory and agency staff fitted in well. The Croft DS0000023060.V261336.R01.S.doc Version 5.0 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Two way communication with residents and relatives indicates that on the whole complaints are appropriately actioned which should ensure that residents and relatives views are both listened and responded to. The deputy manager appears aware of how abuse may manifest itself and is supported by the organisation’s policies, procedures and ongoing training. These measures should ensure residents are protected from abuse. EVIDENCE: The manager sends to the Commission on a quarterly basis a complaints summary. These have generally been handled satisfactorily. Two way communication with residents and relatives should ensure that residents concerns are listened to and actioned. There is a programme of ongoing training in adult protection. The home advertises Care Line in some units. The deputy manager described appropriate actions regarding any potential or actual abuse. It is strongly recommended that adult protection should be discussed in staff meetings. The Croft DS0000023060.V261336.R01.S.doc Version 5.0 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 & 26 The home is generally maintained in good order and is generally clean and pleasant so that the environment meets residents’ needs. EVIDENCE: The Croft is a purpose built home which is modern, bright and welcoming. The home is divided into four separate units, which adds to the homely feel. Most areas, including bedrooms and communal areas, were seen during the tour of the home. Bedrooms seen showed the individuals preferences and personal belongings. There are some areas for redecoration and the manager confirmed that these were in hand. It is strongly recommended that the acting manager and proprietor’s representative regularly tour the building to identify any repairs, refurbishments and health and safety issues maintaining records for inspection purposes. The Croft DS0000023060.V261336.R01.S.doc Version 5.0 Page 18 The inspector re visited bedroom 25 where there was an odour of incontinence which had been rectified and since the previous inspection. Pedal bins have been purchased which should aid infection control. The Croft DS0000023060.V261336.R01.S.doc Version 5.0 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 & 30 Staffing levels and staff deployment must be kept under review and residents dependency levels assessed regularly which should ensure residents’ needs are met. Recruitment records indicate a clear recruitment process which should ensure that residents are protected from potential abuse. Training records showed that most staff have undertaken or have planned mandatory training, this indicates that residents’ needs should be fully met. Agency staff used by the home must be trained and competent to meet residents needs. EVIDENCE: It is evident from time spent with residents and observing staff interactions with residents that a number of residents dependency levels have increased. A significant number of relatives confirmed that staffing levels are a concern in their responses to the Commission’s questionnaire; for example, In your opinion are there always sufficient numbers of staff on duty? Nine out of fifteen replies answered ‘no’. Staffing levels and staff deployment must be kept under review and residents dependency levels assessed regularly which should ensure residents’ needs are met. Records must be maintained for inspection The Croft DS0000023060.V261336.R01.S.doc Version 5.0 Page 20 purposes. This is also of concern with regard to the number of falls reported to the Commission under Regulation 37. It is strongly recommended that the manager conduct an audit of falls to establish if there are any patterns or trends. (See standard 7 and 38 for further detail) The last four weeks rotas studied indicated that there were appropriate levels of staff. From studying the home’s training plan it was evident that there is a rolling programme of most mandatory training. This now includes infection control training. Refresher training in food handling was confirmed by the manager as identified at the last inspection. It is strongly recommended that the manager write to the agency used by the home to confirm that all agency staff have the appropriate training to meet residents needs. Staff recruitment files studied held the essential information as outlined in the standard and schedule It is strongly recommended that all references are supported by an official stamp, headed paper or compliment slip as advised on the reference form. Recruitment information held in the home regarding agency staff was appropriate. The Croft DS0000023060.V261336.R01.S.doc Version 5.0 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 & 38 The manager indicates that she deploys staff and takes her responsibilities seriously to ensure residents live in a well managed home. The manager must apply to the Commission for registration. Systems are in place which should ensure that the home is run in the best interest of the residents. Staff must follow the home’s financial procedures to ensure anomalies do not occur. EVIDENCE: The manager has been recently appointed following her internal promotion from deputy manager. She will need to be registered with the Commission in the coming months. The manager is open to ideas and receptive to improving The Croft DS0000023060.V261336.R01.S.doc Version 5.0 Page 22 practice in the home. She has shown that she takes seriously any requirements set by the Commission and she uses the skills within the staff team. Care plans and discussions with residents indicate that the home is run in their best interest. An advocacy agency supports an open ethos. Relatives generally talked favourably regarding the care of their relatives. The organisation send regularly to the Commissions reports of Regulation 26 visits and the manager informs the Commission under Regulation 37 of any event that effects the well being of a resident. These factors indicate that the home is run in the best interest of residents. Two residents personal money accounts were studied, receipts are kept and records of all expenditure tallied with the total. However, the float to enable residents to access their money did not reconcile itself. It is evident that staff are not following the home’s procedure regarding the proper management of this money. It is acknowledged that a senior manager had checked the monies some days ago when the account had tallied. Since the inspection the Commission has received an acceptable explanation regarding this anomaly. On arrival at the home the office door was wedged open with an object, this was removed immediately. the manager is required to ensure that no door is held open except by such a device as approved and agreed by the fire department. The manager is advised to contact the fire officer to seek advice of appropriate devices. Risk assessments will need to support the use of any device recommended by the fire officer. During the tour of the home the fire officer’s report was discussed and evidence mainly found to ensure these items had been dealt with. The manager is asked to put in writing how she has acted on the fire officer’s recommendations. Fire records seen indicated that these were satisfactory as did lift and hoist services. It is strongly recommended that fire drills are carried out at least twice yearly and that each zone’s call bells are checked more regularly to ensure that there is not an eleven week time lapse between zone1 and zone 11. This will need to be supported by clear guidelines for staff. Bath temperatures are recorded and window restrictors are checked as part of a monthly health and safety check. The home records all accidents and incidents. It is strongly recommended that the manager conduct an audit of falls to establish if there are any patterns or trends. (See standard 7 and 38 for further detail) The Croft DS0000023060.V261336.R01.S.doc Version 5.0 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 X X 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 1 The Croft DS0000023060.V261336.R01.S.doc Version 5.0 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 OP3 Regulation 14 (1) Requirement Timescale for action 31/03/05 2 OP9 13 (2) 3 OP27 14 (1) (a) The manager must ensure that future admissions are supported by a completed assessment of need. Staff training and procedures to support the process along with an audit system must be developed to support the process.( Previous timescale of 31/6/05 not met). The proprietor and manager must explain in writing to the Commission why this requirement has not been met. All staff who are responsible for 31/03/05 recording, handling, safekeeping, safe administration and disposal of medicines must be assessed as competent. The manager must continue to audit the home’s (MAR) sheets. The manager must maintain staff competency records in the home. Staffing levels and staff 31/03/05 deployment must be kept under review and residents dependency levels assessed regularly. Any increase in dependency should be supported by an increase in staffing levels. Records must be DS0000023060.V261336.R01.S.doc Version 5.0 The Croft Page 25 maintained for inspection purposes. 5 OP30 18 (1) The manager must ensure that staff used by the home from an agency are appropriately trained to meet residents needs. The home’s financial procedures must be followed to ensure that there are no anomalies. The manager is required to ensure that no fire door is held open except with a device agreed and approved by the fire department. It is strongly recommended that the manager consults with the fire department to seek advice of appropriate devices to hold open the office door. Risk assessments will need to support the use of any device recommended by the fire officer. 31/03/05 6 OP35 10 (1) (a) 31/03/05 7 OP38 13 (4) 31/03/05 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 OP8 Good Practice Recommendations It is strongly recommended that the manager develop a health intervention sheet to aid in following through residents care. It is recommended that the manager continues to monitor the meal time process and produces an action plan following her research. 2 OP15 The Croft DS0000023060.V261336.R01.S.doc Version 5.0 Page 26 3 4 OP18 OP19 It is strongly recommended that adult protection should be discussed in staff meetings. It is strongly recommended that the acting manager and proprietor’s representative regularly tour the building to identify any repairs, refurbishments and health and safety issues maintaining records for inspection purposes. It is strongly recommended that the manager conduct an audit of falls to establish if there are any patterns or trends. 5 OP38 6 OP38 It is strongly recommended that fire drills are carried out at least twice yearly and that each zone’s call bells are checked more regularly to ensure that there is not an eleven week times lapse between zone1 and zone 11. This will need to be supported by clear guidelines for staff. The Croft DS0000023060.V261336.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 The Croft DS0000023060.V261336.R01.S.doc Version 5.0 Page 28 - 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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