Inspection on 27/11/06 for The Croft

This inspection was carried out on 27th November 2006.

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 12/01/09

The Croft 14/01/08

The Croft 19/04/06

The Croft 27/01/06

The Croft 26/07/05

The Croft 07/03/05

The Croft 16/09/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Croft Barracks Road Bickershaw Wigan Greater Manchester WN2 5PR Lead Inspector Lynn Sharples Unannounced Inspection 27th November 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Croft Address Barracks Road Bickershaw Wigan Greater Manchester WN2 5PR 01942 867186 01942 867386 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) Mr Kevin Harper Care Home 23 Category(ies) of Dementia - over 65 years of age (17), Old age, registration, with number not falling within any other category (23), of places Physical disability over 65 years of age (4) The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 23 service users to include: up to 23 service users in the category of OP (Older People) up to 4 service users in the category of PD(E) (Adults with Physical Disabilities over 65 years) up to 17 service users in the category of DE(E) (Adults with Dementia over 65 years) The service should employ a suitably qualified and experienced Manager who is registered with the CSCI. The Registered Manager must be supernumerary and not included in the staff to service user ratio. Sufficient staff must be on duty at all times who are trained and competent to meet the needs of service users, taking account of changing dependency levels and special needs. 19th April 2006 2. 3. Date of last inspection Brief Description of the Service: The Croft Care Home is located in semi-rural surroundings just off the main road through the village of Bickershaw, and provides residential care and accommodation for up to 24 male and female service users of retirement age. The Homes registration permits the Home to accommodate up to four service users with a physical disability and 17 with a diagnosis of dementia. Nursing care is not provided at this Home. At the time of this report, the scale of fees for this home is from £290.75 to £340. The fees include all costs with the exception of hairdressing, for which the visiting hairdresser makes a small charge. The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of the visit there were twenty one residents living at the home, one resident was in hospital. The home did not know about the visit and it took eight hours and included a site visit to the service. Residents, one relative, the manager and the care staff, cook and handyman were spoken with; 9 surveys from residents and 5 completed comment cards from relatives were received. The files relating to the service users, staff and the home were read and the premises toured. The home has received one complaint since the last visit and the home has investigated this complaint and has provided evidence that these have been dealt with. One complaint has been made to the CSCI since the last visit about the quality of care received at the home. What the service does well: The homes Statement of Purpose and Service User Guide are detailed providing service users and prospective service users with details of the services the home provides enabling them to make an informed decision about an admission to the home. Residents’ individual health, personal and social care needs are clearly recorded. This provides care staff with the information they need to meet the residents care needs. The medication at the home is well managed and promotes good health. The residents spoken with said, “ I definitely receive all the care and support I need”, comments from relatives indicated that the care in the home has improved since the new manager has been in post. Residents have choice and flexibility how they spend their day in the home, and can pursue leisure activities according to their choice and preferences. This allows independence and individuality for each resident. Residents receive a balanced diet offering variety, which reflects the residents’ preferences. Two residents explained that they had been to a mining museum and go out shopping, but they do not have to join in activities if they do not wish to. One resident said that since the new manager has been in post “ there are more things to do now”. The home has a satisfactory complaints system with evidence that residents feel their views are being listened to and acted upon. The home’s policy and training programmes for adult protection and whistle blowing ensure that the homes residents are protected from abuse. The recent investment has improved the appearance of the home creating a more comfortable and safe environment for those living there and visiting. The recruitment practices are The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 6 adequate and appropriate checks are carried out. This ensures that the resident is not put at risk. The staff training provided ensures that the staff are basically equipped to meet the needs of the service users. What has improved since the last inspection? 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 summary of this inspection report can be made available in other formats on request. The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes Statement of Purpose and Service User Guide are detailed providing service users and prospective service users with details of the services the home provides enabling an informed decision about the admission to the home. The home does not provide intermediate care services (Key Standard 6). This standard does not therefore apply. EVIDENCE: The new manager has updated the Statement of Purpose and the Service User Guide these are both in draft form at the moment. The drafts contain all the information a prospective resident and their representative would need to make an informed choice about whether to stay at the home. The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 9 Two contracts were seen and they included all the information a resident would need before moving into the home such as the fees payable and terms and conditions of occupancy. The manager has produced a new pre assessment booklet that personal care, mental state and cognition and a pen picture that includes previous work or social interests, hobbies, leisure pursuits, family background. This is a comprehensive document that includes all the relevant information to assess a residents needs before they move into the home and ensures that these needs will be met. The manager explained that only they visit the prospective resident in their own home or in hospital and that they have received training in assessment. The residents spoken with said that their relative looked round the home before they moved in. The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ individual health, personal and social care needs are clearly recorded. This provides care staff with the information they need to meet the residents care needs. The medication at the home is well managed and promotes good health. EVIDENCE: The seven care plans that were looked at contained detailed and comprehensive care needs assessment that explains how best to support the resident with everyday living such as health, personal and social care needs. The plan is reviewed monthly with updates and changes recorded regarding the residents needs. The resident or relative signs some of the care plans. The care plans contained risk assessments relating to prevention of falls and mobilising. The risk assessments were brief and did not include all the information a carer would need to fully support a resident in all aspects of their care. The manager agreed to amend the risk assessments. The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 11 The care plans included details on personal hygiene, dressing, oral care, vision/hearing/foot care/nail care, continence, medication, eating and drinking, family/social/spiritual involvement, breathing/sleeping pattern, past medical awareness/mood/anxiety. There was evidence that district nurses, chiropodist, diabetic nurses and optical services visited the home. The residents spoken with said that “ I definitely receive all the care and support I need”, comments from relatives indicated that the care in the home has improved since the new manager has been in post. No resident in the home self medicates as the nurses in the home administer all medications for residents. The protocols for the receipt, storage, disposal, and documentation of medications in the home are in accordance with the National Minimum Standards (NMS). The home has purchased a new medicines cabinet, fridge and a new sink has been fitted in the treatment room. The home has changed their dispensing pharmacist and the manager said that this has improved the procedures. The home has a new medication policy and those staff who are responsible for administering medication have received training. In the care plans there is information about the preferred term of address for the residents. The new manager has introduced changes to the laundry, which means that the residents wear their own clothes and this is colour coordinated. In one plan a resident prefers to wear two specific colours and their wardrobe only contains these colours. In the Statement of Purpose there are particulars about arrangements for residents to have their own private telephone, but the home has a portable telephone. Personal care given by the staff was observed to ensure the residents dignity and privacy. Staff were seen knocking on residents doors. Residents said that they receive medical examination in their own room and that the staff are “ caring and kind”. The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have choice and flexibility how they spend their day in the home, and can pursue leisure activities according to their choice and preferences. This allows independence and individuality for each resident. Residents receive a balanced diet offering variety, which reflects the residents’ preferences. EVIDENCE: The home has a member of the care staff that works Monday to Friday 2pm4pm as the activities coordinator. They do not have a set timetable of activities preferring to talk with the residents to find out what they wish to do. The activities include: - bingo, darts, arts and crafts, sing a longs and music. A theatre company visits twice a year and performs at the home. There were photographs of some residents who had participated in a cooking session. There is also information regarding resident’s birthdays and whether the home or family organises this. The care files included information about choice making, including individual routines of daily living, religious observance. The resident’s activities are recorded and information about whether they enjoyed The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 13 the activity is recorded. There was a discussion with the manager about including these details in the daily records as to how the resident coped or responded in the activity, and to their mood, emotions, physical dexterity. The recordings of the resident activities helps to complete a “full picture” of the residents progress, or even identify developing care needs. In one file it said “I like to drink tea and water and I have one sugar in my tea and I prefer a mug”. It was observed that residents were still offered a choice of drinks. Two residents explained that they had been to a mining museum and go out shopping, but they do not have to join in if they do not wish to. One resident said that since the new manager has been in post “ there are more things to do now”. Residents explained that they are able to see visitors in private and the home operates an open door policy. The home has details of advocacy services; it would be beneficial if these details were displayed for all to read. There was a discussion about the home inviting advocacy services to chair residents meetings, the manager agreed with this. The home is not responsible for any residents’ finances. The manager explained that they are exploring the possibility of residents being involved on the interview panel for prospective workers in the home. The resident’s bedrooms contained personal possessions. The residents and relatives were involved in choosing new colours for the bedrooms. The menus looked at offer a varied, wholesome and nutritious diet. The cook explained that they provide special therapeutic diets. Several alternatives and provided and if a resident wished to have something that was not on the menu this was provided. Residents spoken with said that they could have alternatives and that they enjoyed the food. The cook said that they had more crockery now and more equipment to cook with. The home has purchased some new tables, there were table clothes and napkins on the tables and the dining rooms had been redecorated. The home only uses fresh fruit and vegetables and the meal at lunchtime was served in a relaxed unhurried manner. There was information in the care plans regarding plate guards. One relative commented that the quality of the food has improved. All the residents spoken with were complimentary about the food. In the afternoon drinks were served from a trolley and cakes, biscuits or fresh fruit were on offer. In one residents file it stated “ I have two biscuits before I go to bed”. The menus are to be laminated using pictures and placed on the tables to aid choice making. The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with evidence that residents feel their views are being listened to and acted upon. The home’s policy and training programmes for adult protection and whistle blowing ensure that the homes residents are protected from abuse. EVIDENCE: The home has a complaints procedure that is included in the Statement of Purpose; this has been updated last month. The home has received one complaint since the last visit and the home has investigated this complaint and has provided evidence that these have been dealt with. One complaint has been made to the CSCI since the last visit about the quality of care received at the home. The residents spoken with said that if they had any concerns or complaints they would talk to either their relative or the manager. The relatives spoken with said that they had “ no complaints” but said that if they did they would raise this with the manager. The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 15 The home has a policy regarding protection of abuse. There is also a document about “whistle- blowing” that advises staff what they should do if they have such a situation. Some of the staff have received training in Protection Of Vulnerable Adults training, through the National Vocational Qualification (NVQ). The staff spoken with were able to demonstrate an awareness of the different forms of abuse and how to act as an alerter in terms of adult protection. The home must ensure that the remaining staff have received up to date training regarding adult protection. The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,22,24,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recent investment has improved the appearance of the home creating a more comfortable and safe environment for those living there and visiting. EVIDENCE: The home has recently made improvements to the décor and furniture and fabric within the home. There is now a programme of redecoration. The comments from both residents and relatives confirm that there has been worked carried out and that they are pleased with the results. A district nurse who was visiting commented about the overall appearance of the home and how this has been improved. There are toilets close to the lounge and dining areas and these are clearly marked. There are two medi showers and an assisted bath. On first walking into these rooms there was a smell of urine and some bathrooms did not have The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 17 paper towels, the manager addressed this. Eleven of the bedrooms are en suite and all have been provided with new toilets and flooring in the en suite facility. There were grab rails in most corridors, one corridor did not have rails and was a narrow corridor. The homes should risk assess whether the grab rails will impede residents and cause a risk and if so, decide whether the toilet in this corridor should be used. The manager said that they are going to paint the rails in different colours to make it easier for residents to get their bearings in the home. The three bathrooms have a call system that is difficult to reach; the home should ensure that all the residents are able to seek assistance if they need to. Eleven bedrooms have been redecorated and have new beds, carpets, furniture and curtains. The manager said that the all the bedroom are included in the rolling programme of redecoration. The remaining bedrooms had poor quality furnishings and some of the bedrooms did have a malodour that originated from the carpets. The manager explained that if a new resident was not happy with the colour of their room this would be changed to the resident’s specification. The residents can lock their rooms and this was observed on the day of the visit. The laundry has one washing machine and one drier and a sluice is to be fitted shortly. The washing machines have the specified programming ability to meet disinfection standards. The staff were observed to wear protective aprons and gloves for specific tasks. The home has a daily and monthly cleaning schedule. The corridors are to be redecorated and the carpets have been cleaned and are to be replaced. In some areas of the home there was a malodour, which should be addressed when the carpets are replaced. The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recruitment practices are adequate and appropriate checks are carried out; this ensures that the resident is not put at risk. The staff training provided ensures that the staff are basically equipped to meet the needs of the service users. EVIDENCE: The rotas indicate that there are sufficient care staff on duty to meet the residents needs. On the day of the visit there were enough staff on duty to meet residents care needs. There is usually four staff on duty in the morning, 4 in the afternoon and two waking night staff. Some of the staff has worked at the home for many years this provides continuity. There is also a cook, domestic assistance and a handyman. Ten of the fourteen staff have the NVQ level 2 and some have the NVQ level 3, two further staff are signed up to start the NVQ level 2 course. There are no agency staff or trainees working at the home. An examination of a sample of staff records indicated that all new staff had two references, enhanced Criminal Records Bureau checks, statements of terms The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 19 and conditions on their personnel file. Some of the staff records did not have two references the manager said that they would look into this. The home provides an on the job induction, the new staff confirmed that they have a full day induction and then two weeks where they “shadow” another care staff and follow the member of staff observing their practice. The home must ensure that new staff are provided with induction and foundation training that meets the “Skills for Care” specification and that this is recorded. The old records for the staff training did not provide details of the training the staff received. The staff spoken with confirmed that they had received training in manual handling, adult protection. The new manager confirmed that the staff will receive further training and there was evidence that all the staff will be attending a training course on dementia. A condition of registration relates to staff training and the home should ensure that this condition is met. The staff would benefit from training in mental health and diabetes to ensure that they can meet the changing needs of the residents. The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The record of self-review by the registered provider is infrequent and does not provide the home with adequate quality assurance. EVIDENCE: The new manager has been in post a few months and has applied to the CSCI to register as the manager. They have been a manager for four years prior to this home and has many years of experience working in the caring profession. They have the NVQ level 4 in Care and the NVQ level 4 in Management. They have also completed the BTEC level 4 in Medication and in Dementia. It is evident that they have made improvements in the running of the home and the residents and relatives spoke highly of the input they have made since The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 21 being in charge. The staff said that the manager was supportive and that they have learnt more about the care of older people since they have been in post. The manager has held three staff meetings since being in post. The manager said that they have devised a survey that they will be completing early next year. The manager has started residents and relatives meetings. It would be beneficial if anonymous resident and relative satisfaction questionnaires were also conducted. The owner has only completed two reports about the home this year, despite being reminded of their obligation by the CSCI earlier in the year. They must ensure that they visit every month and write a report on the conduct of the home. The home is not appointee for any of the residents and the home has a policy and procedure to ensure that residents’ money is kept safe. Some resident’s spoke of their relative being in control of the finances and that they had enough money for anything they wish to purchase. The new manager has sent training needs analysis to all the staff to find out what training needs they have and this will form the first supervisions. There was no evidence that supervisions took place before the manager was in post. There was a discussion regarding supervision and making certain that the staff receive regular recorded supervision that covers all aspects of practice, the philosophy of care in the home and career development needs. In the care files it was noted that not all accident, injuries were appropriately recorded or reported. The home has current certificates in respect of electrical and gas safety. A current certificate of employer liability was displayed. The handyman completes the relevant checks for the safe running of the home and staff have attended fire drills. The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 22 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 2 X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 2 X 2 The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 23 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 OP21 OP24 OP26 OP22 Regulation 23 Requirement The registered person must ensure that all parts of the care home are kept clean and reasonably decorated. The registered person must ensure that equipment provided at the care home for the use of residents is maintained in good working order. The registered person must ensure that the persons employed at the home receive training appropriate to the work they are to perform including structured induction training. The owner of the home must ensure that his monthly, unannounced visits to the home are conducted thoroughly and that full records are available for examination. (This requirement remains outstanding, timescale 04/07/06 unmet). The registered person must ensure that persons working at the home are appropriately DS0000038461.V315537.R01.S.doc Timescale for action 26/03/07 2 23 08/01/07 3 OP30 18 26/03/07 4 OP33 26 26/03/07 5 OP36 18 26/03/07 The Croft Version 5.2 Page 24 supervised. (This requirement remains outstanding, timescale 19/05/06 unmet). 6 OP38 17 The registered manager must ensure that any accident, injury and incident which are detrimental to the health and welfare of a resident must be recorded. (This requirement remains outstanding, timescale 19/05/06 not met). 26/03/07 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 OP13 OP18 OP30 OP30 OP33 OP36 Good Practice Recommendations It is recommended that the risk assessments are expanded and include all risks to the residents and how this is to be minimised. It is recommended that a local advocacy service be involved in residents meetings. It is recommended that all the care staff receive up to date training regarding adult protection. It is recommended that the staff receive training in mental health and diabetes. It is recommended that all staff receive a minimum of three paid days training per year and have an individual training and development assessment and profile. It is recommended that the home conduct anonymous resident satisfaction questionnaires. It is recommended that care staff receive formal supervision at least 6 times a year. The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Croft DS0000038461.V315537.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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