Inspection on 28/05/08 for The Croft Rest Home

This inspection was carried out on 28th May 2008.

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 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 Rest Home 24/05/07

The Croft Rest Home 30/01/07

The Croft Rest Home 26/04/06

The Croft Rest Home 28/11/05

The Croft Rest Home 20/05/05

The Croft Rest Home 09/12/04

The Croft Rest Home 15/04/04

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE The Croft Rest Home 84 King Street Whalley Lancashire BB7 9SN Lead Inspector Mr Jeff Pearson Key Unannounced Inspection 28th May 2008 09:15 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 Rest Home DS0000009432.V358816.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 Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Croft Rest Home Address 84 King Street Whalley Lancashire BB7 9SN 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) 01254 822821 Lancashire Nursing and Residential Homes Vacant post Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 2007 Brief Description of the Service: The Croft is a detached property set within its own, well-maintained grounds. The home is within easy reach of the main street and facilities of Whalley, including shops, churches, post office, health centre and public houses. The Croft is registered to offer accommodation and personal care to 26 older people. Accommodation is provided in 26 single bedrooms, some with en suite facilities, over two floors. There are lounges on both floors, with a dining room on the ground floor. Smoking for residents is permitted in one lounge area. There is a small lift to provide access to the 1st floor; however, this is not suitable for wheelchair users. A stair lift has been installed. There are various adaptations to assist the residents with self- help and mobility. The garden has seating areas for residents and car parking spaces available. Staff are available to provide assistance with personal care and support 24 hours a day. The home had available a Statement of Purpose and Service User Guide providing information about the care and services available. This information, should help people make an informed choice about moving into The Croft. At the time of this inspection visit, the range of fees charged were between £329.00 and £391.50 per week, there were additional charges for hairdressing, toiletries and newspapers. The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means people using this service experience Adequate quality outcomes. A key unannounced inspection, which included a visit to the service, was conducted at The Croft on the 28th May 2008. The visit took 8½ hours and was carried out by one inspector. The residents, their relatives and staff were invited to complete surveys, to tell the Commission what they think about the care service provided at The Croft, some were received at the Commission. Prior to the site visit, the registered person was required to complete and returned to the Commission an Annual Quality Assurance Assessment (AQAA). This was to enable the service to show how they were performing and provided details about arrangements, practices and procedures at the home. The files/records of two people were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of people living in the own home. We spoke with the residents, acting manager, administrator, owner and staff. Various documents, including policies, procedures and records were looked at. Some parts of the home were viewed. A random unannounced inspection had previously been carried out at the home on the 5th February 2008. A letter following this inspection will be made available to members of the public or other enquirers on request from the Commission. What the service does well: Relatives completing surveys, made the following comments on what they felt the home did well – “There is a delightful atmosphere amongst staff and residents whenever I visit” - “The staff are always cheerful to me and helpful” “Does its best to cater for all needs especially to maintain the dignity of each individual” - “Very caring and compassionate staff always friendly and always pleasant and welcoming”. One resident said, “They are very nice people running the place, they do their job alright” The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 6 People were getting attention for health care needs, one resident said ”They listen to what I say and act on what I say i.e. getting a doctor” The residents personal privacy needs were being dealt with sensitively and they were being treated with respect and as individuals. Residents said, “I think they respect us much as we respect them” “you get treated how you want to be treated” and “They treat us with respect, they tease sometime, but I know when they are teasing” Most people were happy with the arrangements for activities and daily routines were fairly flexible, one comment made was “I am happy with activities in my own room at the Croft, but I can join in any activity I wish” What has improved since the last inspection? What they could do better: The resident’s individual care plans needed to include full details of all their needs and how they are to be met, to ensure staff know exactly what to do for each person. To make sure people are properly and safely supported with their medication, some medication practices and guidelines needed improvement. So people have opportunity to be consulted and be involved, the home should arrange regular residents meetings. Even though most people were satisfied with the food, catering arrangements should be looked at to promote more choices and flexibility. To make sure managers and staff do the right thing to protect people living at The Croft, some guidelines needed changing to provide better guidance. Recruitment practices also needed improving to protect the residents. The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 7 To make sure the home is being properly run for the benefit of the residents, a manager must be registered to run the home and the owner must arrange for unannounced inspection visits to be carried out and reported on. To show improvements in the home are ongoing, plans should be made indicating what is to be upgraded and when. 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 Rest Home DS0000009432.V358816.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 Rest Home DS0000009432.V358816.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): 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process helped ensure peoples’ needs and wishes, were considered and planned for before they moved into the home. EVIDENCE: The homes guide had been updated and was readily available. Most residents completing surveys indicated they had received enough information about he home prior to moving into The Croft, some had been supported by their relatives, comments made were, “I was given full information by the family I was very satisfied” and “My family helped me with the choice and I had a visit.” During the random unannounced inspection of 5th February the Commission was provided with a revised statement of purpose, which contained all the relevant information. The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 10 Records seen showed the home had completed an assessment, before people moved in, taking into consideration their individual needs abilities and wishes in matters such as - personal hygiene, sleep routines, mobilisation, continence, vision, religion, history of falls, personal safety, hobbies, routines and social contacts. The acting manager said, people were being advised verbally following assessment if the home could meet their needs, to provide clear assurances this needed to be put in writing. The acting manager said people were being encouraged to visit to look around the home and stay for tea; some people had stayed at the home for short periods which had helped them make their decision to move in. One resident said, “I came in for two weeks respite care and I made sure I wasn’t going home again” Following the assessment an initial care plan had been devised. The AQAA (Annual Quality Assurance Assessment) completed by the acting manager and administrator, showed that obtaining more detailed background histories was an area for improvement at the home. At the time of this inspection The Croft did not provide intermediate care. The Croft Rest Home DS0000009432.V358816.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): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all health and personal care practices and procedures were effective in ensuring people’s individual needs are properly met. EVIDENCE: The residents spoken with were satisfied with care and attention they received at the Croft. This response was also reflected within surveys completed by residents and their relatives. One resident wrote “If I need help the staff always look after me,” Most residents indicated in surveys that they always get the care and support they need. Care plans were looked at as part of ‘case tracking’ The format in use provided scope for peoples’ individual needs to be identified on a wide range of relevant matters, such as, sleep routines, mobilisation personal safety, hobbies, social contacts and religious needs. However, the plans seen were lacking in detail The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 12 and clear instructions for staff to follow in order to properly respond to peoples’ individual needs. For example, one plan stated ‘needs assistance of the carer in all aspects of personal hygiene’, which was not specific and detailed enough to effectively instruct staff in providing person centred care. This lack of precise directions to staff meant that continuity of care is largely dependant upon staff memory and good communication systems, with a potential for care needs not being properly met and care being reactively, rather than proactively planned. Records showed that peoples care needs were being monitored and reviewed. Although the residents spoken with were not very aware of their care plans, the acting manager said they had been read with them and some had signed in agreement with them. Health care needs were included with care plans. Records and discussion showed people were getting attention from healthcare professionals such as GP as District Nurses. Most residents completing surveys indicated they always receive the medical support needed, one wrote ”They listen to what I say and act on what I say i.e. getting a doctor!” Additional assessments were available in relation to nutrition and pressure areas, risk assessments were being carried on matters such as, physical health, falling and bathing unassisted/unattended. Senior staff had undertaken medication training in 2006, therefore further training should be provided in due course. Progress had been made on ensuring medication records are accurate and clear. One person was prescribed a ‘variable dose’ item, but there were no clear individual instructions on how to manage this. To promote independence, two people were self-administering topical items, but there were no assessments to show their ability to do this had been properly considered. Medication policies and procedures were available, they were quite brief and did not provided clear instructions on administration, there were some additional instructions, these needed to be included in the formal procedures. The homes library was accessed through the medication storage room, this did not promote safe storage/handling of medication or the protection of confidential information. There were no systems in place for auditing and improving medication management systems and the AQAA did not identify any specific areas for development. The residents spoken with considered they were treated with respect. Observations of care practices during the inspection indicated peoples’ privacy needs were being respected; staff spoke with residents in a courteous manner. People were being supported to maintain their appearance; a hairdressing ‘salon’ was available which enabled people to receive attention in an appropriate setting. The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 13 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at The Croft had opportunities to join in activities and had lifestyles, which generally matched their expectations. EVIDENCE: The residents spoken with indicated they were generally happy living at the home, “It’s a good family atmosphere ” said one person “I dont know how anyone could grumble” commented another. Some routines seemed flexible, the residents spoken with said they could go to their rooms whenever they wished. Residents’ surveys indicated they were mostly happy with the activities available, including dominoes, music and dancing. A list of possible activities was seen, this was being used as a reference for staff. Records were kept of the activities held each day and of the residents’ participation. Some people preferred not to join in and their wishes were respected. One person said “Its alright, you get fed up but its alright” The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 14 The homes’ visiting arrangements were included in the homes guide. Residents spoken with indicated they could see people at any time. Representatives from various religious faiths visited the home, one comment made was, “I can join in any activity I wish to i.e. the prayer services etc in the lounge” The acting manager said efforts were being made to support people to go into the village, one resident explained how they visited the shops. Risk assessments were available in relation to unescorted outings, helping in the home, using appliances. There had not been any recent residents meetings held at The Croft, but the acting manager had considered introducing this type of activity, this would be useful in providing opportunity for the giving and receiving of information, making suggestions and enabling the residents to make group decisions. Involving residents more and offering a wider range of activities had been identified as an area for improvement in the AQAA. Relatives completing surveys considered the home always supports people to live their chosen lifestyle. All the residents spoken with expressed an appreciation of the food provided at The Croft, with comments made such as “Very nice and varied”, “I like all my meals.” “Food – no complaints about the food – usual run of meals breakfast lunch and tea” and “Food on the whole is okay, alternatives are provided”. The Cook spoken with said, “They can have whatever they want for breakfast” Records were kept of peoples individual likes, preferences and any food allergies. The Cook said the managers would tell her about the likes, dislikes and special diet of new people. A set meal was offered at lunch, with alternatives provided on request. Mealtimes were discussed with some residents, mention was made that 4pm was a little soon for tea, this matter and offering further choices at mealtimes, was discussed with the acting manager. The residents were not provided with matching crockery, which could further enhance their mealtime experience. The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 15 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 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all policies and procedures were effective in providing robust safeguards for people using the service. EVIDENCE: Residents completing surveys and those spoken with, indicated they knew how to make a complaint, one comment made was “The staff are easily approachable and very understanding” others said they had “no complaints”. All relatives completing surveys said they were aware of the complaints procedure and that the home always responds appropriately, to any issues or concerns. The complaints procedure, which was on display in the home and included within the home’s guide, provided clear instructions on making a complaint, expected timescales and details of other agencies, including the Commission. No recent complaints had been made at the home. Individual risk assessments had been carried out in relation to the residents being at risk of abuse from others including possible exploitation. All the residents completing surveys indicated they knew who to speak to if they were not happy with things at the home. Records showed most staff had received training in April 2008 on the protection of vulnerable adults. Action had been taken to further develop safeguarding policies and procedures and staff had The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 16 signed to confirm their awareness of this information. However, the policy inferred those who allege abuse may come under scrutiny for making such allegations, which could result in people choosing not to disclose or pursue allegations. Mention was also made of ‘minor incidents abuse’ that these may not be reported further by the management, which did not appear to provide appropriate safeguards for people using the service. The staff ‘whistle blowing’ procedure included some good information, but needed the full contact details of the local Social Services and The Commission for Social Care Inspection, to ensure any unresolved bad practice is appropriately reported. The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. 19 and 26 This judgement has been made using available evidence including a visit to this service. The accommodation provided the residents with a comfortable and clean place to live. EVIDENCE: The residents spoken with were satisfied with the accommodation provided at the Croft, most had personalised their bedrooms with their own belongings, one person had provided their own furniture, which had helped create a sense of home and ownership. Residents’ comments were, “It’s very nice” and “My bedroom is nice enough for me”. Some improvements had been made at the home, a number of bedrooms had been decorated and the ground floor lounge was being re-painted. A stairlift had been provided and some internal alterations had been made to improve facilities, for example the hairdressing The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 18 ‘salon’. A full time maintence person had been employed to carry out repairs and redecoration. The standard of decoration and accommodation was satisfactory; most furnishings were domestic in appearance, however, some of the furniture and fittings were showing signs of general deterioration and were in need of renewal to provide a more appealing environment. The homeowner indicted improvements were to be made at the home. The home was found to be clean and free from unpleasant odours. Satisfactory laundry equipment and facilities were available; a designated cleaner was employed at the home. All residents completing surveys indicated the home is always fresh and clean, one wrote, “My room is cleaned 3 times a week” Although there was an indication within the AQAA completed by the administrator and acting manager that the home was to be upgraded, there were no records showing a programme of refurbishment and renewal enhance the environment and facilities at The Croft; which meant we did not have clear assurances of the progress to be made within set timescales. The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. To ensure the resident’s needs are effectively and safely met, The Croft must improve and show continued good practice in relation to staff recruitment, staffing levels, training and development. EVIDENCE: Residents spoken with made positive comments about the staff team, describing them as “alright” and “great” one comment made was “In all the time I have lived at the Croft I have never heard any member of the staff raise a voice to any resident, their patience is much to be praised”. The staff rota indicated staffing levels were satisfactory, however, staff had mentioned in surveys that on occasion there were not enough staff, one comment made was “Residents should have adequate time devoted to them and this is not always possible”. One resident spoken with said, “They often seem a bit short of staff”. Staffing levels were discussed with the acting manager, who considered that things had now improved and covering shifts was no longer a problem. She said, extra staff could be brought in if needed in response to residents needs and for providing escort with appointments. Most residents indicated in surveys that staff were available when they needed them. The importance of ensuring sufficient staff are available, shifts are The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 20 always covered and staffing levels are continually reviewed and adjusted accordingly, was emphasised in discussion with the acting manager and administrator. Improvements had been made with staff training; this was being given high priority at The Croft. Most of the care team had NVQ (National Vocational Qualifications) level 2, three carers staff had attained NVQ level 3, six were working towards this. Training courses in safe working practices, such as First aid and Moving and Handling, had been completed and were going. Additional more specialised training had been arranged for example, dementia care further training was being planned for. There had been a low turnover of staff at the home; the recruitment records of the last member of staff to be employed were examined. The person had returned to the home following six months away, an application form had not been completed nor references sought which meant not all required checks had been carried out for the protection of the residents. Most staff surveys confirmed appropriate recruitment practices had been carried out. Records were seen of staff induction training, most staff surveys indicated this had covered everything needed; ‘Scills for Care’ induction guidance had been obtained. Staff meetings were being held more frequently. The AQAA (Annual Quality Assurance Assessment) completed by the acting manager and administrator, showed staff supervision and NVQ training as areas for future development. The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Croft must ensure continued effective leadership and good management practices, for the benefit and well being of the people living in the home. EVIDENCE: This inspection showed some progress in the general management of the home, including meeting previously made requirements, residents, relatives and staff made positive comments about the general running of the home. However, the inspection highlighted a number of matters needing further development. There had again been some changes in management since the last main inspection and the home still did not have a registered manager. The The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 22 acting manager said it was her intention to apply for registration with the Commission. The timescale previously set for this requirement was 04/07/08. Quality assurance processes were discussed with the acting manager. The AQAA (Annual Quality Assurance Assessment) had been completed. Effectively completing the AQAA was discussed with the acting manager and administrator, in particular, ensuring enough details are noted and using the process for ongoing quality assurance and developing the service. The acting manager said that surveys had been recently been given residents, relatives and District Nurses. Although it was apparent the homeowner was making regular visits to the home, there were no reports available, showing structured unannounced monitoring visits had been carried out to ensure the home is being properly run for the benefit of the residents. The homes guide included information on the various methods of fee payment payments of fees; a computerised system was being used for financial transaction of payments and charges. It was advised the programme set up to ensure accounts are managed in relation to each person, to promote confidentiality and individuality. Accountable systems and practices were in place for managing resident’s monies. Arrangements were in place for all staff to receive training in safe working practice subjects. The homes AQAA indicated the servicing and checking of equipment and installations, records were seen in support of this. Health and safety policies and procedures were available. Some bedroom doors wedged open at the occupants request, this was discussed with acting manager, it was advised this practice be reviewed and safer alternatives considered. The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 19 Schedule 2 Requirement For the protection of the residents, recruitment practices and procedures must always ensure all required checks are carried out prior to staff commencing employment. To ensure the home is effectively and consistently managed for the benefit of the residents. A registered manager must be appointed. This requirement has been outstanding since 19th December 2005 To make sure the home is being properly run for the benefit of the residents, arrangements must be made for unannounced inspection visits to be carried out with findings being reported upon, in accordance with the requirements of this regulation. Timescale for action 01/07/08 2. OP31 8 04/07/08 3. OP33 26 01/07/08 The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 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 Refer to Standard OP3 OP7 OP9 OP9 OP9 OP9 Good Practice Recommendations To provide clear assurances the home is able to meet peoples’ needs, prospective residents are to be informed in writing following their assessment. Care plans should be in sufficient detail to provide clear guidance to staff, of the actions to be taken, to meet the residents personal and social care needs. A suitable auditing system should be introduced to ensure safe medication practices. To make sure people are safely supported to manage their own medication, such as topical creams, their individual abilities need to be properly assessed and planned for. To make sure people are properly supported to receive their medication, individual instructions should be written in relation to variable dose and when required medication. To make sure staff have clear up to date guidance and instructions, medication policies and procedures should be reviewed and updated to include reflect current best practice. The location and arrangements for medication storage should be reviewed and addressed, to promote safe and secure practices. To promote opportunities for consultation and involvement, residents meetings could be introduced as regular activity. Catering arrangements should be reviewed and developed to promote further opportunity for choice, flexibility and independence. The Commissions report ‘Highlight of the Day’ - should be obtained for reference. To make sure people are properly protected, the safeguarding policies and procedures must be amended to include more appropriate and clear instructions for managers and staff to follow. The staff ‘whistle blowing’ policy should include appropriate referral details. To show improvements to the home are ongoing, a written programme of refurbishment and redecoration, with timescales should be completed. 7 8 9 OP9 OP12 OP15 10 OP18 11 OP19 The Croft Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Port Way Preston PR2 2YQ 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 Rest Home DS0000009432.V358816.R01.S.doc Version 5.2 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!