Inspection on 02/08/05 for The Croft Nursing Home

This inspection was carried out on 2nd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Croft Nursing Home 21/02/08

The Croft Nursing Home 06/07/07

The Croft Nursing Home 31/01/07

The Croft Nursing Home 24/05/06

The Croft Nursing Home 17/02/06

The Croft Nursing Home 11/01/05

The Croft Nursing Home 03/08/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Croft Nursing Home 43 - 44 Main Street Stapenhill Burton on Trent Staffordshire DE15 9AR Lead Inspector David Cowser Announced 02 August 2005 @ 09:20hrs 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 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 Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Croft Nursing Home Address 43 - 44 Main Street Stapenhill Burton on Trent Staffordshire DE14 9AR 01283 561227 01283 562535 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) Tawnylodge Limited TBA Care Home with nursing 36 Category(ies) of 2 DE(E) registration, with number 36 OP of places 1 PD 15 PD(E) The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 15 PD(E) - 1 may be PD over 42 years Date of last inspection 11 January 2005 Brief Description of the Service: Croft Nursing Home is registered to provide both nursing and personal care in the following categories; physical disability elderly (34 beds), conditions associated with old age (15 beds), dementia (2 beds) and 1 younger person with a physical disability. The home is located in the residential area of Stapenhill, Burton on Trent and is close to amenities and served by public transport. The home is pleasantly situated with grounds and external sitting areas. Adequate car parking, external roadways and pathways are provided. Accommodation is provided on ground floor and first floor served with stairs and a shaft lift. There are ten single bedrooms and thirteen double bedrooms (27 single rooms). One bedroom has an en-suite facility. There are four assisted bathrooms, and also toilets are conveniently situated throughout the home. There is a large main lounge and a dining area, along with a separate smaller lounge and a conservatory, all on the ground floor. A hairdressing salon is also provided. Services and facilities including laundry and catering are suitable, with adequate staffing levels. Nursing and personal care is provided by an acting care manager (RGN), supported by nursing staff and teams of care assistants. Health service professionals such as district nurse, community psychiatric nurse, and physiotherapist are accessed when required and local GP’s and a pharmacist service the home. The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine announced visit was made on the 2 August 2005 @ 09.20hrs. The inspection was undertaken using the National Minimum Standards for Older People as a reference. The total time spent for the inspection, including pre and fieldwork, amounted to 12hrs. The acting care manager was in charge of the home; accompanied by an RGN and five care assistants. The ancillary staff on duty included; two domestic workers, one laundry person, one-maintenance person, a cook and an assistant. The administrative support person was also on duty. These staffing levels were adequate to meet the needs of current 29 residents in the home. The total of 29 residents, aged between 58 and 96 years of age, included 18 patients receiving nursing care and 11 with personal needs. The inspection included the following elements; a tour of the building, observation and inspection of records relating to provision of care, discussions with six residents and six visitors, discussions with staff members on duty, observation and sampling of other services provided, such as catering and laundry, and an inspection of the managerial aspects such as staffing issues, quality assurance and health & safety. The last routine inspection took place on 11 January 2005. Two complaints had been received relating to care practices and additional visits to the home had been necessitated. During the past 12 months there had been 5 deaths recorded, and no residents currently had a pressure area. No incidents or reports of abuse of any kind had been received and policies and procedures seen covered these issues. Since the last inspection no residents had attended an A&E department, or sustained a fracture. Residents had been able to choose the home following an assessment and invitation to visit the home. It was evident that aspects of care had been addressed, and the associated documentation had been produced following advice given during the complaints investigation. Service user plans had been re-written, based on the community care plans completed by social workers. Health, personal and social care needs were generally being met and documented. Privacy and dignity aspects for residents were being upheld. However choices relating to food and activities were not fully offered. The home was fit for purpose and provided a safe environment for the residents and staff. A homely atmosphere had been created, and the premises were clean, warm and tidy. Adequate areas for residents were provided including; communal spaces, dining/activity space, bathing/toilet facilities, and The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 6 bedrooms. Services and facilities, including catering and laundry, were adequately provided. Health and safety aspects had been addressed, but shortfalls were noted regarding provision of lifting aids, adjustable beds and two small areas of defective floor covering. Staffing levels and skill mix had at times been inadequate to meet the assessed needs of the existing residents, particularly between 07.30 and 08.30 on weekdays. Recruitment and retention of staff aspects had not been good with relatively high staff turnover. Staff training had not been given a high priority, with only 2 carers out of the 21 employed having level 2 NVQ qualifications. Induction training had been done but not documented, and all staff had not received regular supervision. The acting care manager was not entirely clear about her management role within the company. It was evident that she had to request each and every item from her superiors within the company, who were not always available. Staff told the inspector that often basic items requested by the care manager were refused or limited on financial grounds. The responsible individual or a company director declined to attend this announced inspection. Separate correspondence will follow requiring confirmation of the management arrangements and the financial viability of this home. There was no evidence of quality assurance taking place, questionnaires had been sent out and returned from relatives. Records had been correctly filed and stored. Requirements or recommendations made during this visit are listed at the end of this report. In view of the number and nature of the requirements made, and the staffing issues, this home has been risk assessed in the red category and will receive additional inspection visits until the issues have been satisfactorily resolved. What the service does well: What has improved since the last inspection? Since the last inspection the care plans have been rewritten. Staff training has begun, but still requires input. The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 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 Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 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 standard(s) 3 Individual health, personal and social cares needs had been established prior to admission and were generally being met by staff, which individually and collectively had the necessary skills and experience. EVIDENCE: The documentation seen, and a discussion with residents/representatives, evidenced that residents had been assessed prior to admission and they had been enabled to make a choice about the home. All involved had the opportunity to visit the home prior to choosing an admission. Several residents spoken to had visited the home, and had a meal prior to deciding to stay, and this was seen documented within the care plans. The community care plans provided by the social worker, as part of the individual needs assessment process, were seen within the service user plans. Residents asked confirmed that they had been fully involved and were in agreement with the assessments. The records seen and a discussion with the staff evidenced that care staff, individually and collectively, had the necessary experience and skills to meet the assessed needs of the current service users. The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 The assessed health and personal care needs of residents had been documented and were being met, with acceptable standards of care being delivered. There was a safe system for the receipt, storage, administration and disposal of medicines, which safeguarded residents. Also residents were treated with respect, privacy and dignity, during the caring process, which had enabled each resident to maintain these values. There had been shortfalls in the supply of incontinence products. EVIDENCE: Five service users, and five relatives spoken to, all commented positively about the care being provided. Though all commented on the need to provide more staff. One daughter spoke about her mother being unable to go for breakfast until 09.30 or 10.00 due to staff shortages. The service user plans and associated documentation had been rewritten, following several requests from CSCI inspectors. The plans were now meaningful and reflected the current condition of residents. The documentation seen and a discussion with both residents and staff members evidenced that health and personal care needs were being met. Service user care plans must now be reviewed on a monthly basis, as agreed. The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 11 NHS facilities and professionals including community nurses, medical consultants and clinical nurse specialists had all been accessed when required, and these events were seen recorded. A local GP practice and a Boots pharmacist service the home, and there is a good working relationship with them. Records of their visits and outcomes were seen documented. The medicines within the home, medication administration records, controlled drugs book and drugs returned book, were all checked and no errors were noted. It was observed that a safe system was in place, and that the comprehensive medicines policy documentation seen was being complied with. The documentation seen evidenced that only trained nurses administered medicines. No resident was ‘self medicating’, but locked facilities were available. During the inspection it was observed that privacy and dignity were being afforded to residents, and there was very good interaction with staff. Care staff were seen knocking on doors before entering. Two residents told the inspector that they were treated with respect. Staff told the inspector of the shortfalls in the supplies of incontinence products and nets. They had borrowed from another home within the group on occasions, but this was not satisfactory. Adequate supplies of incontinence products must be provided to meet the needs of the service users. The records evidenced that during the past 12 months there had been 5 deaths recorded, and no residents currently had a pressure area. The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Residents were satisfied with their lifestyle in the home, and they had been able to exercise choice and influence decisions affecting them. Residents unable to make a decision had been assisted by care staff that was knowledgeable on their likes and dislikes. However several residents commented that they were denied eggs at breakfast and that no fresh fruit was available. Contact had been maintained with relatives and friends of residents. There had been no opportunities to access the local community, and minimal activities had taken place. Catering aspects were good within the constraints placed on the home, and the food supplies delivered. The staff had not been able to meet each resident’s social, cultural, religious and recreational interests and needs primarily due to staffing numbers. EVIDENCE: Several residents told the inspector that their views had been listened to, and that they had been able to influence some aspects of the running of the home e.g. mealtimes, menus, beverage facilities for visitors. These comments had been documented along with the feed back from the resident/relatives questionnaires, and they had been acted upon. Contacts had been maintained, where possible, with relatives and friends and this was seen documented. Residents spoke of their visitors and their involvement with the home. Several visitors attended the home during this inspection, and told the inspector of the good links and communication with The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 13 them. There had been no trips out to the community. There was no activities folder or evidence of activities either inside or outside the home. There was no activities organiser or a designated member of staff. Care staff had been concerned about this situation and had arranged between themselves a lottery in order to buy some items for the residents. A summer fête had not been arranged. Activities and entertainment must be coordinated and include trips out where appropriate. Several residents spoke of their satisfaction with the meals and choices offered. The menus and catering records were examined and evidenced that the dietary requirements of residents were met, with the exception of fresh fruit and vegetables. The records evidenced that residents’ needs with diabetes, and special diets, had been met. The cook when asked said that fresh meat from a local butcher was delivered on a weekly basis, the records seen confirmed this. However there were no records of adequate supplies of fresh vegetables and fruit. The inspector enquired if residents had enjoyed strawberries or raspberries during the recent ‘season’. It was understood that none had been supplied to the home. On inspection it was evidenced that the egg supply had been reduced from one box to half a box per order. The residents told the inspector that there had been disappointed that they no longer could have eggs at breakfast time. The cook said that she would still put eggs on the menu on a Saturday morning because they really appreciated a poached egg and it was not fair to deny them. The milk order had been reduced and this had necessitated watering down the semi-skimmed milk. Adequate supplies of fresh fruit, eggs and milk must be provided, as required by residents. The inspector sampled the mid-day meal during the inspection and it was very good, meeting all requirements. Several residents were unable to make a decision regarding choice of meal, due to their current condition, and the inspector saw them being assisted by staff who were knowledgeable of their likes and dislikes. The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Complaints or grumbles are listened to and resolved. The home policies and procedures protected residents from aspects of abuse. Staff and relatives were knowledgeable on the complaints procedure. EVIDENCE: An examination of the complaints book, the relevant policy and procedure documentation, and a discussion with staff and residents, evidenced that complaints and grumbles were listened to and dealt with in the correct manner. Since the last inspection one complaint had been recorded or brought to the attention of this commission. This had been partly upheld and satisfactorily resolved. During the inspection one negative observation was made by a visiting daughter; due to the staff shortages the residents on the ground floor had to wait until 09.30 or 10.00am some mornings before they could be got up and go for breakfast. Care staff asked said that this was correct but they have altered their work pattern when they are short staffed. ‘Thank you’ and complimentary cards were seen from appreciative relatives. No incidents of neglect or abuse of any kind has been reported. The policy documentation seen, and a discussion with staff confirmed that residents are protected from all forms of abuse. No residents had attended an A&E department since the last inspection, or sustained an injury. There was no documentation to evidence that the above issues had been discussed during staff induction, training and on-going supervision. However staff asked were knowledgeable on this subject. The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,25,26 The premises were fit for purpose, with adequate personal and communal facilities provided. The home provided a safe and well-maintained environment for residents. The home was clean, warm and tidy, and had a comfortable atmosphere. The home provided 29 single room occupancy. Adequate ancillary staff were employed which ensured that the hotel services aspects were well addressed. Cleaning fluids supplied to the home were substandard and made it difficult for staff to ensure that the home was kept in a hygienic condition. Adjustable beds had not been provided for nursing patients requiring them, which had not assisted both patient and staff members. EVIDENCE: A tour of the premises, and a check on the maintenance documentation, verified that the premises were fit for purpose, clean warm and tidy. The duty rosters evidenced that adequate ancillary staff were employed. Staff when asked told the inspector of their knowledge on infection control. Adequate hand washing facilities were available throughout the home, with one exception. A wash hand basin should be installed, with paper towel holder and soap dispenser, within the 1st floor bathroom, as discussed. The laundry and sluice facilities were seen to be fully compliant. The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 16 The records evidence that maintenance of the premises was being given a high priority. Hot water temperature checks, and emergency lighting/fire alarm tests were seen up to date and correct. There are no outstanding issues known from the Environmental Health or the Fire Prevention departments. A tour of the building evidenced that 10 of the 34 beds are in single rooms (29 single bedroom occupancy). Residents spoken to were very happy and settled in their rooms. The following shortfalls were noted during this inspection; The carpet in the dining room must be made good, and also the dirty marks removed. Consideration should be given to replacing this floor covering, as discussed. The vinyl floor covering at the entrance to the kitchem must be made good, as agreed. Lifting slings and handling belts, as requested by staff, must be provided to ensure safe movement of residents. Adjustable beds should be provided where required for nursing patients, as agreed. The cleaning fluids and preparations supplied to the home should be suitable to enable the domestic staff to maintain a clean and hygienic home. Staff had brought in their own proprietary brands of cleaning fluids in order to clean the washbasins etc, as the poor quality fluids supplied were substandard. The inspector assumed that yet again these cheaper items supplied had been part of a cost cutting exercise. The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 The assessed needs of service users had not always been met by an adequate number of suitably trained staff. Recruitment procedures for staff had been correctly addressed, which had contributed to the protection of service users. However staff turnover had been high and the home currently had staff vacancies. Staff training had not been given a high priority, and only 10 had achieved level 2 NVQ qualifications. Further training is required in order to ensure that high standards of care are always delivered. The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 18 EVIDENCE: The duty rosters seen, and a discussion with the manager and the staff, evidenced that there had been shortfalls in staffing. Adequate numbers of care staff had not always been on duty to meet the needs of the existing service users. Staffing levels had not been maintained as at 1st April 2002 and following a discussion with the acting manager and her deputy it was agreed that this shift cover was adequate for the existing residents needs (Staff to resident ratios of 1:5,1:6,1:10). Staffing rosters, for the 29 service users, were checked and the following was noted; 1RGN 5 Care assistants were required. Some weekdays Morning shift only 1RGN 2 care assistants were on duty between 07.30am and 08.30am. Then 1RGN 4 C/A were provided for the rest of the shift. Afternoon shift 1RGN 4 Care assistants were required. Many shifts had 1RGN 3 C/A on duty. Night Shift 1RGN 2 Care assistants were provided as required. The acting care manager and her deputy when asked stated that higher management had refused them agency cover on the grounds of insufficient funds. Staff told the inspector that they were tiered of having to cover additional shifts due to staff shortages. There appeared t be a high incidence of staff going off sick. Separate correspondence has been sent relating to the staffing and funding issues. In addition to the above adequate ancillary staff were rostered on duty throughout the week. The records seen evidenced that 7 trained nurses were employed and 21 care assistants, of which 2 (10 ) were trained to NVQ level 2 or above. Training should be provided to ensure that the current level of 10 care staff with NVQ level2 qualifications be increased to the target of 50 , as discussed. The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 19 The homes recruitment policy, procedures and documentation were examined and recruitment issues had been handled correctly. Staff had been subject to POVA/CRB comprehensive checks, and these were seen recorded. Staff asked stated that they had job descriptions and contracts of employment. Training had not been given a high priority and the training records of individuals were not available for inspection. Some care assistants had benefited from ‘in house’ and external training, which had covered the needs of the registered client group. Staff told the inspector that they had not been afforded the time off and encouraged to study. Staff asked stated that they had been given an induction by the acting care manager, but little had been documented. New starters should complete the induction programme, including all documentation, within their first six weeks. The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35,38 There was no evidence that the home was being well managed and no quality assurance was in place. Internal financial aspects were correctly addressed and recorded, with safeguards to residents. Financial issues regarding the running if the home needed further clarification. Health and safety issues had been given a high priority and managed well. It was not readily apparent that that the home was always being run in the best interest of service users. EVIDENCE: From observations made, and discussions with service users and staff, it was not readily apparent that the home was always being run in the interests of service users. There was no formal quality assurance system. Feedback forms were seen from residents and their representatives, which had positive comments. A quality assurance system should be implemented and documented. The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 21 A check on the records and a discussion with both residents and representatives evidenced that all service users had the opportunity to handle their own finances and all residents and families had chosen to do so. Day to day monies of residents were checked and money held reconciled with the ledger. Inventories of valuables and belongings brought into the home were seen recorded. No health and safety issues were noted during this inspection, including a tour of the home, with the exception of the defective floor coverings in the dining room area previously referred to. The documentation seen for checks and examination of plant and equipment was all correct and up to date. The staff spoken to confirmed that health and safety issues are given a high priority. Some staff appraisel had taken place. Care staff must receive formal supervision, which is documented, at least six times per year, as agreed. Training should be provided to enable the acting care manager to attain level 4 NVQ qualifications, as discussed. Separate correspondence has been sent to establish the financial viability of this home, as no company representative was present to give this reassurance and to clear up the other items raised that have financial implications. The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 23 Are there any outstanding requirements from the last inspection? The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 24 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. 2. Standard OP7 OP36 Regulation 15(2)(b) 18 (2) Requirement Service user care plans must be reviewed on a monthly basis, as agreed. Care staff must receive formal supervision, which is documented, at least six times per year, as agreed. The carpet in the dining room must be made good, and also the dirty marks removed. Consideration should be given to replacing this floor covering, as discussed. The vinyl floor covering at the entrance to the kitchem must be made good, as agreed. Adequate supplies of fresh fruit, eggs and milk must be provided, as required by residents. Adequate supplies of incontinence products must be provided to meet the needs of the service users. Lifting slings and handling belts, as requested by staff, must be provided to ensure safe movement of residents. Activities and entertainment must be coordinated and include trips out where appropriate. Care staff must be working be working at the home, at all times, in sufficient numbers as appropriate for the health and welfare of the service users. Timescale for action 2 September 2005 2 October 2005 2 September 2005 3. OP19 23(2)(d) 4. 5. 6. OP19 OP15 OP8 23(2)(d) 16(2)(i) 12(1)(b) 2 September 2005 Immediate Immediate 7. OP22 13(5) 9 August 2005 2 September 2005 Immediate 8. 9. OP12 OP27 16(2)(m) 18(1)(a) The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 25 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 OP24 OP33 OP30 OP21 OP31 OP28 OP26 Good Practice Recommendations Adjustable beds should be provided where required for nursing patients, as agreed. A quality assurance system should be implemented and documented. New starters should complete the induction programme, including all documentation, within their first six weeks. A wash hand basin should be installed, with paper towel holder and soap dispenser, within the 1st floor bathroom, as discussed. Training should be provided to enable the acting care manager to attain level 4 NVQ qualifications, as discussed. Training should be provided to ensure that the current level of 10 care staff with NVQ level2 qualifications be increased to the target of 50 , as discussed. The cleaning fluids and preparations supplied to the home should be suitable to enable the domestic staff to maintain a clean and hygienic home. The Croft Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Nursing Home E51-E09 S22321 The Croft V237989 020805 Stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!