Inspection on 06/07/07 for The Croft Nursing Home

This inspection was carried out on 6th July 2007.

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 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 31/01/07

The Croft Nursing Home 24/05/06

The Croft Nursing Home 17/02/06

The Croft Nursing Home 02/08/05

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 Peter Dawson Unannounced Inspection 6th July 2007 08:30 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 Nursing Home, DS0000022321.V344908.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 Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Croft Nursing Home, Address 43-44 Main Street Stapenhill Burton On Trent Staffordshire DE15 9AR 01283 561227 01283 562535 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) Tawnylodge Limited Ms Jane Measey Care Home 30 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (30), of places Physical disability (1), Physical disability over 65 years of age (15) The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 15 PD(E) - 1 may be PD over 42 years Care Manager commences NVQ level 4 in management within 12 months of registration 31st January 2007 Date of last inspection Brief Description of the Service: The Croft Nursing Home is registered to provide personal and nursing care for the following categories- Old age 30 beds. Physical disability aged over 65 years of age, 15 beds. Dementia over 65 years of age 2 beds. Accommodation is provided on the ground floor and first floor served with stairs and a shaft lift. There are 14 single bedrooms and 8 double bedrooms. One bedroom has an en-suite facility and the rest have a washbasin installed. There are three assisted bathrooms and one shower room; toilets are conveniently situated throughout the home. There is a large main lounge, a dining room and a conservatory on the ground floor. 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 has limited garden areas due to its hilly incline but there is space for several cars to park. Weekly fees are from £312 - £421 (There are no top-up fees). Additional charges are made for newspapers/magazines, telephones, toiletries and hairdressing services. The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out by one inspector on one day from 8.15 a.m. – 5.00 pm. The Registered Manager was present throughout. The National Minimum Standards for Older People provided the basis for this inspection. An Annual Quality Assurance Assessment (AQAA) was completed by the Providers/Manager and forms the basis of some information in this report. Information was also gained from inspection of care planning information and general records and documents available in the home. There was an inspection of the physical environment. There were 25 people in residence at the time of this inspection (including 1 in hospital), most were seen and many spoken to. Most comments were positive about the home and care provided. Some residents said that activities were non-existent and that entertainment was provided infrequently. Some clearly would like to go out occasionally “if only to the park for a change of scenery” General comments from residents included “ I am cared for well” and “Everyone is marvellous, Matron is wonderful” Two visitors were seen who visit the home daily/weekly. Both stated that they were happy with the care provided for their relative and were kept informed of progress or significant events affecting their health or well-being. What the service does well: A small nursing home where residents are able to establish close relationships with staff and visitors. Visitors said they are made welcome and have observed relaxed relationships with staff. Care plans are detailed and provide the comprehensive information needed to meet the needs of residents. The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 6 Health care records are good and there is a pro-active approach to health care matters. Staff know when to refer to external healthcare professionals. The standard of healthcare is good. There is flexibility of routines to enable residents to make choices about when, where and how care is provided. What has improved since the last inspection? What they could do better: The statement of purpose should be updated to clearly identify the service and facilities offered and there should be written confirmation to new residents that the home can meet their needs. Hoist slings should be removed after hoisting and hydration improved for some residents with drinks throughout the night. Activities are poor and almost non-existent. The home should consult residents and provide activities to meet their social and recreational needs. Greater stimulation would improve quality of life. Many items of equipment in the kitchen area require replacement. The newly installed shower room must be connected to mains water. Police checks should always be obtained prior to employment of staff. The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 7 Some areas of statutory training for staff should be provided. The temperature of hot water outlets in resident areas must be reduced immediately and monitored closely. The safety of gas fat fryers in the kitchen area must be reviewed and serviced by a reputable CORGI installer. Work identified in the Fire Officers letter dated 16th May 2007 must be carried out as soon as possible. Outcomes of all complaints should be recorded. The Registered Manager is constantly referred to by all residents, staff, visitors and professionals as Matron. This is a dated term and does not encompass modern concepts of care. 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 Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 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 Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. The statement of purpose must be updated to inform choice of home. Pre-admission assessments and procedures are satisfactory. Residents should be informed in writing prior to admission that their needs can be met. All residents have contracts. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose/Service Users Guide was being updated at the time of the last inspection. This has not been done and is now required. All matters listed in Schedule 1 must be included, a copy given to all residents/relatives and a copy sent to the Commission. The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 10 Contracts are in place for funded residents with a copy of the Local Authority contract provided and for those self-funding the home provides a private contract. Prospective residents are assessed in their current environment prior to admission. This was confirmed in pre-admission assessments seen on file for those recently admitted and formed the basis for care planning. Files seen also showed a Care Management Assessment had also been obtained prior to admission. At the time of the last inspection a letter to residents/’their representatives was in the process of being provided. This has not been done and is a requirement of this report. The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Care plans contain clear and concise information based upon assessed need. Health care needs are well documented and met. Early referrals to specialist healthcare workers were evidenced. There is a safe system of medication in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of care plans were seen relating to both recent admissions and longterm residents. The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 12 The standards of care planning were good. There was adequate information identified from assessments and ongoing reviews to provide the level of care required. The plan of a recently admitted resident contained assessments for nutrition, continence, waterlow, dependency levels and the support required to ensure good healthcare. Actions required for catheter care, PEG feeding and allerices were included. Risk assessments were in place relating to mobility and falls. Chosen lifestyles were defined in care planning information also. Treatment for pressure ulcer present at the time of admission had continued with appropriate pressure relieving equipment in place, including a clear regime for continued wound care. After 4 weeks there had been improvement in the pressure ulcer and this was adequately documented. On the day of inspection the dietician had been called because of diarrhoea and urgently obtained a prescription for alternative input for PEG feed. The home had acted swiftly in referring the matter to a specialist health care worker. Only one other person had a recently observed superficial sacral skin break which was being treated appropriately. There are 4 alternating pressure mattresses and a range of mattress overlays and cushions, provided following risk assessment. It was noted in the lounge area that a resident had been hoisted and the sling left underneath her and on top of the pressure-relieving cushion. The sling clearly negates the pressure relieving properties of the cushion. This person is also in the high risk category of waterlow and nutritional risk assessments. Clear records are kept relating to weighing – all residents are weighed monthly. Some have food and fluid intake and output charts where is a particular risk. Daily records of fluid intake are recorded and monitored by the nurse in charge. Records showed that there was little or no fluid intake for these residents during the night shift and it is important that where people are awake at night or are disturbed that the opportunity should be taken to provide fluid intake to improve hydration. Care plans are reviewed on a monthly basis with a sheet to record the review and who was involved. There was no evidence of plans being reviewed with residents/relatives. Residents are checked at 2 hourly intervals throughout the night. This was discussed and it was recommended that staff should check at hourly intervals. There are adequate staff numbers to do this. A good service is reported from local GP services. A recent written feedback from local GP stated “issues are dealt with promptly and efficiently” The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 13 There is a fairly high dependency level in the home. 6 people require total assistance with feeding, 3 are PEG fed, a large proportion require the use of a hoist for moving and handling. The medication system was inspected. The system is supplied by Boots Chemists in MDS (blister-pack) form. Medication is double checked when received. MAR sheets had been correctly completed, with no gaps. The disposal of medication is recorded – there is a count of all medication through the system to ensure an audit trail is available to secure the system. In files seen, it was noted that a medication review had taken place by telephone. The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. The social, recreational and religious needs of residents are not met. A programme of internal and external activities should be provided. Residents should be consulted about their needs in this area. Family contacts are promoted. Residents state satisfaction with food provision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Several residents spoken with said that they were satisfied with the care provided at The Croft and they had no complaints. There is no activities programme and no evidence that the social and recreational needs of residents are provided for. The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 15 Entertainment brought into the home is infrequent one resident said that they had “not had entertainment for ages”. External contacts are few and limited mainly to contacts with relatives. Many residents do not go out. One said he had been out once in the past year, for a walk in the park for his birthday – he would like to go out occasionally. Another said she had been out only once in the past 2 years. There are currently no clergy involved with residents or pastoral care provided. There is a large lounge area which naturally accommodates 2 smaller groups. There is also an excellent conservatory with views of the neighbourhood. Unfortunately in the hotter weather the doors cannot be opened to reduce temperature and residents have to retreat to the inner lounge to escape the heat. The door apparently cannot be opened due to one resident with dementia care needs who may wish to leave. The home should consider ways of dealing with this to allow residents greater use of the conservatory and/or be able to sit in the small external area beyond the conservatory. During the day residents were sitting in the lounge areas, mainly without conversation with each other, some read newspapers, others watched TV, many were asleep. Staff were seen to engage with residents as time permitted usually whilst carrying out care tasks. Efforts must be made to provide stimulation and activities for residents and some external contacts promoted. At the time of the last inspection activities were being reviewed to provide “more variety”. A Quality Assurance survey on display in the reception area (date not known) showed more activities were needed and 2 Co-ordinators were to be appointed. There is a 4 weekly menu with choices of dish at all mealtimes, including hot choice at tea time and some home baking of cakes. The menus showed a reasonable diet choice. Catering staff spoke with enthusiasm about food provision and clearly maximising choice on what appeared occasionally to be a limited budget. Soft food diets and diabetic diets are provided with wellpresented liquidised meals. Some residents had meals served in bedrooms. Mealtimes are flexible, it was good to see residents arriving for breakfast in the dining room after 11.00 a.m. Residents spoke highly about food, comments included: “very good food, you can eat as much as you like”. The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The complaints procedure is satisfactory and available to all. Training for staff in the protection of residents is needed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure available in the home for residents and visitors which is concise and satisfactory. No complaints have been received by the home or by the Commission since the last inspection. A “Minor complaints” book has been established in the reception area and included opening of parcel for resident, mal-odour in bedroom and missing spectacles. All were ticked and marked “addressed”. It is important that complaints are seen to be taken seriously and that outcomes are recorded, enabling people to see what action has been taken. There has been on external training course in the Protection of Vulnerable Adults. The Manager has attended this course and cascaded the information to staff. Individual training for staff in this area is important. The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 17 The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is poor. Kitchen equipment is poor and needs replacement/maintenance. Hot water exceeds the required maximum limits in resident areas. Action needs to be taken to ensure the safety of residents. Bedrooms and communal areas are generally adequately furnished and satisfactory. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Reported improvements to the building recently are replacement windows, replacement sluice and additional shower (wet) room. The shower room has been completed for some time and provides a good facility, however the water supply has not been connected to it and this is required. The future The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 19 improvement/maintenance plan is not known at this time and the providers should send a copy of the plan to the Commission. There are 14 single and 8 shared bedrooms and a sample of rooms were seen. There is one en-suite room. Toilet areas are located near to bedrooms and the communal areas and residents have commodes if they wish. Bedrooms were adequately furnished and personalised. The standards of hygiene throughout the building were satisfactory. Clearance of items in the laundry and sluice are required, there were black bags full of clothing and general “clutter” in the sluice areas. These must be cleared in the interests of infection control and fire safety. There were large amounts of incontinence pads in some bedrooms that should be stored elsewhere. A drawer full of tights/socks in the bathroom area should also be cleared. Equipment in the kitchen area require replacement/maintenance as follows: A sink tap was hanging loose with drip tray under-sink The 6 slice toaster will only toast 2 slices and one-side. The rubbish bin leaks liquids onto the floor and requires replacement. The domestic-type hand-held liquidiser is not suitable for its purpose and should be replaced with a standard type with container. (6 residents have liquidised food). The cold-water feed to the hot-water boiler rises from the floor and is not fixed, it hovers above the boiler which is mounted on a base with insufficient height to fill the teapot with safety. The two free-standing fryers are gas-driven and have to be lit by staff with matches at floor level. The risks are obvious. The providers must send urgently a copy of the maintenance schedule for these items to the Commission. A sample of hot water outlets in bedrooms were taken and all exceeded the required maximum of 43C. The temperature must be reduced immediately – this is referred to in Standards 31- 38 below. The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is adequate. Numbers of staff are maintained but with some difficulty. More staff members need to be available to cover shifts. Statutory staff training required in some areas of work. Police checks must be made prior to employment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staffing levels at this time for the 3 staff shifts is 5:4:3 – these figures include one nurse throughout the 24 hour period. These numbers are maintained with some difficulty due to the fact that Bank Staff are not employed and there is very restricted use of agency staff. Additionally only 4 nurses are employed (including the Manager) two of who are part-time. This means that the Manager has to fill the gaps in the nursing rota and often unable to have the required 2 days for Management duties. The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 21 The Manager was working on the rota on the day of this inspection and throughout the day was also contacting many agencies to try and arranged care assistant cover for the following morning. There is no depth of staff – bank, casual or regular agency to cover staff absences. Several people have high dependency needs and the pressures of the morning shift were evident with 6 people to feed individually, a large proportion requiring 2 staff to assist with personal care and the medication round taking about 1.5 hours. - Although occupancy rates are currently lower it is not possible to further reduce staffing below the present level. There are adequate support staff including administrator, catering, domestic and laundry staff. Throughout the inspection staff were helpful and co-operative and seen to treat residents with patience and respect. Personal care was provided securing the privacy an dignity of the person. Instances of positive engagement were seen between residents and staff throughout the care support processes. Staff training records showed that there has been training since the last inspection in: dementia care, Stoma Care, The Liverpool Care Pathway and COSHH. There are shortfalls in the areas of Moving & Handling training, Firs Aid, and Fire Safety. This is statutory training and needs to be addressed. There is a staff meeting every 4-5 months – records not seen on this visit. A sample of staff files were seen – records generally contained all items in Schedule 2 with the exception of one instance where a member of care staff had been employed prior to POVA or CRB checks. These must always be obtained prior to employment. The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is poor The Responsible Individual does not visit the home regularly to offer support. Increase in staffing numbers would allow management time for the Registered Manager. Two areas require immediate action to ensure safety of residents. Work must be completed to ensure fire safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 23 The Registered Manager is currently studying the Registered Managers award which she hopes to complete in December 2007. This was a condition of registration. She has the required experience to run the home. Her required 2 days off the rota to complete management tasks is often not possible due to shortage of nursing staff available to cover absences. She had been on the rota for 4 days in the week of this inspection and still trying to field staffing issues, shortages etc. There appear to be restrictions upon the appointment of additional staff. The Responsible Individual (representative of the providers) does not visit monthly or leave a report in the home. It is a requirement under Regulation 26 that the Responsible Individual visits the home on an unannounced basis once each month. A report on his/her findings must be left in the home for the Manager and available for inspection. Two Health & Safety issues require immediate attention – they are: In bedrooms sampled for inspection it was found that the hot water supply exceeded the required maximum 43C. Immediate steps must be taken to reduce the temperature of these outlets to ensure resident safety. Regular checks must monitor temperatures in future. and The ignition system for the 2 fat fryers in the kitchen must be reviewed immediately to ensure safety. A copy of the servicing of the fryers must be sent to CSCI. All issues raised in the Fire Officers letter dated 16/05/07 must be addressed to ensure fire safety. All staff should have external annual fire training. It was reported that the Fire Marshalls are providing this training for other staff. Additional first aid training is required to ensure one trained person is on duty at all times. The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 24 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 2 3 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 1 2 2 2 3 3 1 2 STAFFING Standard No Score 27 2 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X X X 3 1 The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4(1)(2) Requirement Statement of purpose must reflect the facilities & services offered and include all items in Schedule 1. Confirm in writing to residents that needs can be met following assessment. Remove hoist slings from under residents who have pressure relieving cushions. Residents with nutritional deficits must be given drinks during the night to improve hydration. A programme of activities must be established in consultation with residents to meet their social, recreational and pastoral care needs. Items of equipment identified in kitchen area must be maintained or replaced. Shower installation must be connected to the water supply Satisfactory POVA or CRB checks must be obtained prior to employment of staff. Staff training required in Moving & Handling, First Aid and Fire prevention. DS0000022321.V344908.R01.S.doc Timescale for action 06/07/07 2 3 4 5 OP4 OP8 OP8 OP12 14(1)(d) 12(1)(a) 12(1)(a) 16(2)(m)( n) 14/07/07 14/07/07 14/07/07 31/08/07 6 7 8 9 OP19 OP21 OP29 OP30 23(2) (c ) 23(2)(j) 19(1)(b) 18(1) 06/08/07 31/07/07 14/07/07 31/08/07 The Croft Nursing Home, Version 5.2 Page 26 10 OP32 26 11 12 13 OP38 OP38 OP38 13(4) 13(4) 23(4)(a) (b) The Responsible Individual must visit the home unannounced on a monthly basis and a report left in the home. Hot water outlets in resident areas must not exceed 43C & regular checks recorded. Process for igniting 2 gas fryers in kitchen must be reviewed & service record forwarded to CSCI Work identified in the Fire Officers letter dated 16/05/07 must be carried out. 14/07/07 06/07/07 06/07/07 31/07/07 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 Refer to Standard OP16 OP19 Good Practice Recommendations Outcomes of complaints must be recorded in minor complaints book to clarify action taken. Inappropriate items stored in laundry, sluice and bathrooms identified should be removed. The Croft Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Local Office Commission for Social Care Inspection Unit D, Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Nursing Home, DS0000022321.V344908.R01.S.doc Version 5.2 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. 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