Inspection on 30/01/07 for The Croft Rest Home

This inspection was carried out on 30th January 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 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 28/05/08

The Croft Rest Home 24/05/07

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Croft Rest Home 84 King Street Whalley Lancashire BB7 9SN Lead Inspector Mrs Lynn Mitton Unannounced Inspection 30th January 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Croft Rest Home DS0000009432.V330895.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.V330895.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 Mr Kyle Goldsmith *** Post Vacant *** 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.V330895.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider should at all times, employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection The home can accommodate up to 26 persons in the category of OP who require personal care. When the service user occupying Room 9 moves out of this room this can no longer be used as a bedroom, and the Commission must be informed. 26th April 2006 2. 3. Date of last inspection 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, aged 65 years and over. Accommodation is provided in 24 single bedrooms, some with en suite facilities, and one double room with en suite facility. There is a small lift to provide access to the upper floor; however, this is not suitable for wheelchair users. There are various adaptations to assist service users with self- help and mobility. There are lounge areas on both floors, and a dining room on the ground floor. Smoking is permitted in one lounge area. The garden has seating areas for service users and there is car parking space available. Fees per week range from £315 - £355.50. There was information available to potential residents advising them of the facilities and the care they could expect whilst living at The Croft. The Croft Rest Home DS0000009432.V330895.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted on 30th and 31st January 2007. Since the previous inspection, the home has a new owner. A new manager had been appointed, but was not yet registered with the Commission. The manager of the home completed a pre inspection questionnaire. The inspector spoke to residents, visitors to the home and to the care staff on duty at the time of the inspection. Throughout the report there are references to the “tracking process”, this is a method whereby the inspector focuses on a small representative group of residents. Records regarding these people were inspected. Three residents was case tracked, their file examined in detail and two care staff member’s files were also case tracked. 18 of the Commissions resident’s questionnaires were returned, and 5 visitors/relatives questionnaires were returned. Comments and findings of these surveys are referred to throughout this report. The inspector conducted the inspection with the manager, the administrator and registered person. During the inspection a number of records, policies and procedures were also viewed. What the service does well: One residents relative wrote; “I feel the care home does really care for the occupants ensuring they are adequately fed and kept clean neat and tidy”. There was clear information about the terms and conditions of residents stay at The Croft. Visitors were made welcome at The Croft, and could visit at any reasonable time. Mealtimes were a social occasion and the food served was varied and enjoyed by the residents. Resident’s independence was encouraged, and some had opportunities to maintain contact with the local community. There were sufficient staff on duty to meet service users needs. The Croft Rest Home DS0000009432.V330895.R01.S.doc Version 5.2 Page 6 The attitude of the staff and management is to run the home around the needs and choices of the residents. Resident’s finances were dealt with in a satisfactory manner. Residents and their families felt they could approach the management team if they had any concerns. The general layout and décor of the home provided comfortable and clean surroundings, and was warm, tidy and clean, and mostly free from offensive odours. What has improved since the last inspection? What they could do better: Up to date and accurate information about the agency was not always available to all residents and their families. The admission procedure does not ensure that sufficient information about residents care needs was always obtained before their arrival at The Croft. Care plans did not fully document resident’s personal care and health needs, nor did they fully demonstrate how they were to be met. Safe administration, recording and disposal of resident’s medication was not in place. A regular recorded programme of activities would ensure that residents had opportunities for their enjoyment, mental and physical stimulation. The home complaints policies must contain information which ensures that complaints will be dealt with in an effective and timely fashion. Revision of The Croft’s protection from abuse policies and procedures, and staff awareness training would be of benefit in ensuring the safety of the residents, and give care staff clear guidelines. Staff do not have required accredited training to better meet the needs of residents. Recruitment and selection procedures do not fully protect residents. The Croft Rest Home DS0000009432.V330895.R01.S.doc Version 5.2 Page 7 The views of residents and visitors about the running of the home had not been sought recently. Health and safety issues must be routinely checked and maintained in order to safeguard the health and safety of the residents and staff team. 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.V330895.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.V330895.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): OP1, OP2, OP3 & OP6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Up to date and accurate information about the home was not available. There was clear information about the terms and conditions of residents stay at The Croft. The assessment procedure does not ensure that sufficient information about individual care needs was always obtained before admission. EVIDENCE: One residents relative wrote; “The Croft is a good place we had heard of its reputation and a few months before we actually needed it. When the time came for my mother to go into care it was the first place I contacted felt lucky The Croft Rest Home DS0000009432.V330895.R01.S.doc Version 5.2 Page 10 to get the vacancy they had. Three months later and my mum seems to be settling in nicely”. One resident wrote; “I came here after an emergency after a fall, but decided to stay as I was happy with the care and kindness and I didn’t want to be a trouble to anyone”. There was a Statement of Purpose and service user guide in place this was out of date and needed updating to contain relevant information. A new contract had been developed and was seen by the inspector to contain all required information. The inspector was advised these were due to be implemented and distributed to all residents in the near future. There was evidence that assessments of need had been completed for three residents case tracked prior to their admission to the home. The information on the files was not always detailed enough to fully identify and meet their needs. The format used was discussed with the manager and one had not been signed or dated. Intermediate care was not provided at The Croft. The Croft Rest Home DS0000009432.V330895.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): OP7, OP8 OP 9 & OP10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans did not fully document resident’s personal care and health needs, nor did they fully demonstrate how they were to be met. Safe administration, recording and disposal of resident’s medication was not in place, posin a potential risk to residents. EVIDENCE: The inspector noted that the content and detail on the care plans case tracked had significantly improved since the last inspection. Information on each resident was still recorded on a Cardex System, a medical model. There was some information identifying each resident’s health and care needs, but not what support was needed in order to meet those needs. There was no evidence that the care plan had been reviewed to ensure that any changes The Croft Rest Home DS0000009432.V330895.R01.S.doc Version 5.2 Page 12 were documented. Two of the three care plans seen demonstrated that the resident or their next of kin had been involved in their care plans. The inspector was advised that a new care plan format would be developed and implemented in the near future. This was discussed at length with the manager. The records were stored securely by the end of the inspection. The care plans case tracked did not have a resident photograph in place. Policies and practices for the safekeeping, recording, administration, storage and disposal of medication had improved since the previous inspection. Medication was stored and administered via a blister pack system; there was no overstocking of non-blistered medication. The controlled drugs and register were seen and in order. The medication fridge was in order with the temperatures recorded daily. Refrigerated medication had been dated on opening. Medication being returned to the pharmacist was correctly recorded and the pharmacist signed receipt of these drugs. The inspector advised that any additional medication received and hand written onto the Mar sheet, must have a second signature to ensure accuracy. The inspector advised that a homely remedies policy and procedure should be developed and implemented. Residents told the inspector that they were spoken to and treat with dignity and respect and gave examples of this. The inspector observed positive, caring and respectful interaction between residents and care staff. One visitor to the home wrote; “I never notice anyone with dirty clothing and the people I have visited in their rooms have clean and tidy accommodation”. The Croft Rest Home DS0000009432.V330895.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): OP12, OP13, OP14 & OP15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The programme of activities does not ensure that residents had enough opportunities for their enjoyment, mental and physical stimulation. Resident’s independence was encouraged, and some maintained contact with the local community. Mealtimes were a social occasion and the food served was varied and enjoyed by the residents. Visitors were made welcome at The Croft, and could visit at any reasonable time. EVIDENCE: One resident’s relative wrote; “We are always made to feel welcome when we visit my mum”. One resident wrote; “I love playing dominoes”. Another resident wrote; “The staff are often get diverted by other residents when I am trying to have a conversation with them”. The inspector was advised that records were kept of any residents’ recreational activities on their daily records. One visitor to the home wrote; “I wonder if The Croft Rest Home DS0000009432.V330895.R01.S.doc Version 5.2 Page 14 there is the opportunity to play board games, cards, dominoes etc., if the residents would like to – organised in small groups by a member of staff. It may be that they do this, but I haven’t been there to see it”. The inspector observed resident’s exercising choice and control over day-today elements of their lives. Care staff were seen to respect residents choices and opinions. The inspector was advised that clergy from the local Church’s visit residents on a regular basis. One visitor to the home wrote; “I am sure they allow ministers of various Christian groups to go in. Our local priest visits monthly or unless urgently required. There were a number of visitors to the home on the day of the inspection. One resident was taken for a visit out of the home by a relative. A payphone was available and seen to be used by residents. One resident went out into Whalley on her own and a risk assessment was now in place with this regard. Information for relatives was on display on the foyer notice board. Residents are encouraged to bring personal possessions to the home. The inspector was advised that all but two residents’ personal allowance finances were dealt with by the home. The inspector randomly checked 3 residents personal allowance records and monies were found to be correct. The homes 3 weekly rotating menus were seen. Varied meals were offered to residents with different dietary needs. Choices of food were available for breakfast, tea and at suppertime. Specialised cutlery was seen to be in use. One resident told the inspector; “The food is lovely here, there’s always a choice”. Another resident wrote; “No cook could suit all the people all the time, but if you have a special request it is willingly dealt with”. There are 2 diabetics and the inspector was advised these are dietary controlled. 2 residents have their food liquidised. The inspector and manager discussed how liquidised food was presented. One resident is supported to feed. Fridge and freezer temperatures were checked and recorded daily and these records were seen. The inspector was advised that it was hoped to refurbish the kitchen. The inspector was pleased to note bowls of fresh fruit around the home for residents to help themselves from. By the end of the inspection, there were sufficient tables at the dining room to seat all the residents. The Croft Rest Home DS0000009432.V330895.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): OP16 & OP18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints policies and protection from abuse policies and procedures must be reviewed and revised to meet contemporary practice. Residents and their families felt they could approach the management team if they had any concerns. EVIDENCE: One residents relative wrote; “If there were any issues I would go to see the manager”. Another resident wrote; “All problems are dealt with quickly and willingly”. 16 out of 18 residents who completed the Commissions questionnaire indicated that they knew how to make a complaint. There had been no recorded complaints to the home or the Commission since the previous inspection. The complaints procedure was seen, and this was on display in the homes communal areas. The inspector advised that the complaint policy was in need of further development. Three informal complaints had been made to the home since the previous inspection. The inspector noted that they had been recorded in the complaints record book and included an outcome, ensuring that they had been satisfactorily resolved. The Croft Rest Home DS0000009432.V330895.R01.S.doc Version 5.2 Page 16 The inspector noted there was a protection of vulnerable adults policy – this was in need of further development. The inspector advised that reference should be made to abuse being a criminal act, and that if this is the case, what action should follow. All policies and procedures should be reviewed on a regular basis. A whistle blowing policy was in place and had good content. Not all care staff had undertaken recent prevention of abuse training. The inspector advised that this matter should be given high priority. The Croft Rest Home DS0000009432.V330895.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): OP19 & OP26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The general layout and décor of the home provided comfortable and clean surroundings, and was warm, tidy and clean, and mostly free from offensive odours. Not all aids and equipment met resident’s needs. Health and safety issues regarding the safekeeping of residents must be addressed as a high priority. EVIDENCE: The inspector was advised that plans were being considered for a new passenger lift or a stair lift to be installed at some time in the future. The inspector was advised that the residents with mobility difficulties now had bedrooms on the ground floor, and only the residents who were not wheelchair The Croft Rest Home DS0000009432.V330895.R01.S.doc Version 5.2 Page 18 users had bedrooms on the first floor. The inspector was advised that all possible solutions continued to be considered as a matter of urgency. Resident’s rooms seen were furbished with their own belongings and were seen to be homely and personalised. The home was clean and tidy, ensuring a pleasant environment for people living at The Croft. The garden was attractive and well maintained. The inspector was advised that the ground floor double bedroom was being considered being changed into a single bedroom and a hairdressing room; and that that the 1st floor lounge was being considered being changed into two bedrooms, or one bedroom and a smaller lounge. The sliding door to the rear staircase was locked and had “fire door” sticker on it. The inspector was advised that it was not a fire door (had a glass panel in it) but was so marked to keep wandersome residents from going upstairs. The inspector and manager also discussed the fire exit at the rear of the building on the 1st floor. The inspector advised that the fire officer be consulted on these matters. Three bedrooms were malodorous and one bedroom carpet was in need of cleaning. One care staff member who was living in the attic was due to leave in the near future. The laundry room was clean and tidy, and hand-washing facilities were now in place. The Croft Rest Home DS0000009432.V330895.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): OP27, OP28, OP29 & OP30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were sufficient staff members on duty to meet service users needs. Staff do not have required accredited training to better meet the needs of residents. Recruitment and selection procedures do not fully protect residents. EVIDENCE: One resident wrote; “The staff are very generous in nature”. Another resident wrote; “I am constantly amazed by the way the staff work so hard and never loose their patience”. One visitor to the home wrote; “From what I observe staff have the right skills and experience to look after residents properly, the staff appear helpful and friendly to the people there”. The staffing rota was examined and it demonstrated that there were 3 care staff on duty between 7.30am and 10pm, plus management team, usually 9 – 5pm Monday to Friday. There were 2 wake and watch night staff between 10pm and 7.30am. Cleaners were employed for 25 hours per week, and cooks The Croft Rest Home DS0000009432.V330895.R01.S.doc Version 5.2 Page 20 employed for a total of 40 hours per week. A handyman also worked 40 hours per week, and an administrator also worked full time. There were no staff employed under the age of 18 and no senior care staff aged under 21 years. A task rota was in place, ensuring that care tasks are completed for all residents. The inspector advised that the volunteer must have a CRB check. The inspector was advised that three out of fifteen care staff had obtained NVQ2 qualification. A further 5 care staff were due to sign up to undertake this training in the near future. Three staff recruitment files were case tracked and one was found to have minor shortfalls in the documentation required by legislation. The inspector attended a staff meeting that had been planned prior to the inspection. It was noted that about one third of the care staff team attended this meeting, despite reminder notices being posted around the home advising staff of the importance of attending. The three care staff case tracked had all received 1:1 support meetings. Handover meetings are held at the end of each shift. A significant number of staff training needs had been identified, including moving and handling, 1st aid, food hygiene, infection control and fire prevention/evacuation procedures. The inspector was advised that arrangements were being made to ensure that these training needs would be met in the near future. The inspector advised that induction training must comply with Skills for Care induction and foundation training. The Croft Rest Home DS0000009432.V330895.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): OP31, OP33, OP35 & OP38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager designate had not been in post long enough to have a significant impact on care practice. The views of residents and visitors about the running of the home had not been sought recently. Resident’s finances were dealt with in a satisfactory manner. EVIDENCE: The new manager had been in post since November 2006. An application for the manager’s registration with the Commission had not yet been received. The manager has 14 years experience in caring for older people. The Croft Rest Home DS0000009432.V330895.R01.S.doc Version 5.2 Page 22 The registered person made an assurance to support the manager to ensure that the standard of care would improve in the forthcoming year. The manager advised that a business plan was due to be developed on the day of the inspection with the registered person. The inspector was advised that a residents questionnaire was due to be developed, and that it was hoped this would be sent out to residents and relatives and regular visitors to the home in the next few weeks. The inspector advised that this should be posted out to residents and their regular visitors (family, friends and visiting professionals) twice a year, and the response collated and published. The registered person said he was not appointee for any residents. The administrator did have involvement in 21 resident’s personal allowances. On checking 3 residents’ purses, there were no discrepancies noted. As previously mentioned in this report a number of health and safety training issues had been identified as outstanding. For example, Fire safety training for all staff, moving and handling training for 6 staff, 1st Aid for 11 staff, health and safety training for 11 staff, basic food hygiene training for 14 staff and infection control for all staff. The inspector noted that the fire alarm system had been independently checked 2nd February 2007. Some previous certificates could not be located. The last fire drill had been conducted 29/01/07. The fire extinguishers were last tested in June 2006. There was no evidence that care staff had received prevention of fire training. There were no records to demonstrate that the emergency lighting had been tested. There had been a Gas Safety check completed in April 2006. A portable appliance test had been completed in January 2006, and the 5-year electrical wiring certificate had been completed in July 2005. The passenger lift had been serviced in February 2006. Water temperatures were being regularly tested and recorded. The Croft Rest Home DS0000009432.V330895.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 2 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 The Croft Rest Home DS0000009432.V330895.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 OP1 Regulation 4&16 Schedule 1 Requirement A Statement of Purpose and service user guide must be produced in accordance with the Care Home regulations. A copy of this document must be supplied to the Commission and the service user guide be available to every service user and any of their representatives. The registered person must not admit residents to the home unless they have been assessed to ascertain that the home can meet their needs. Timescale for action 28/09/07 2. OP3 14 30/03/07 3. OP7 15(1) The registered person shall have 01/06/07 in place a written plan as to how the residents’ needs health and welfare are to be met. This requirement has been outstanding since 20th May 2005 The registered person shall have in place a written plan as to how the residents’ needs health and welfare are to be met. This requirement has been outstanding since 19th December 2005. DS0000009432.V330895.R01.S.doc 4. OP8 15(1) 01/06/07 The Croft Rest Home Version 5.2 Page 25 5. OP9 13(2) 6. OP16 22 & Schedule 4 (11) 13(6) 7. OP18 8. OP19 23(n) 9. OP28 18 (1a&c) 10. OP29 19 Schedule 2 The registered person shall make arrangements for the recording, handling, safe keeping, administration and disposal of medication. This requirement has been outstanding since 20th May 2005 The complaint policies and procedures must be in accordance with this legislation. This requirement has been outstanding since 20th May 2005 The registered person must ensure that by staff training or other measures, to prevent residents from harm, abuse or being placed at risk or harm or abuse. This requirement has been outstanding since 20th May 2005 Suitable adaptations, equipment and facilities including passenger lifts, as may be required must be provided. The registered person must ensure that a minimum of 50 of care staff have achieved the NVQ 2 in Care award. This requirement has been outstanding since 19th December 2005 The registered person must operate a thorough recruitment process at all times. This requirement has been outstanding since 20th May 2005 01/06/07 01/06/07 01/06/07 28/12/07 28/12/07 01/06/07 11. OP30 12, 18 1(a&c) &19 12. OP33 24 (3) Persons working in the care 28/12/07 home must receive training appropriate to the work they perform. This requirement has been outstanding since 20th May 2005 The registered person must 01/06/07 provide evidence of consultation with residents regarding the quality if care provided at the home. This requirement has DS0000009432.V330895.R01.S.doc Version 5.2 Page 26 The Croft Rest Home 13. OP38 13 been outstanding since 20th May 2005 The registered person must ensure that any activities undertaken by residents are so far as is practicable free from avoidable risks. This requirement has been outstanding since 19th December 2005 01/06/07 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. Refer to Standard OP12 Good Practice Recommendations Opportunities should be given for regular planned social and recreational activities. The Croft Rest Home DS0000009432.V330895.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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.V330895.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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