Inspection on 12/09/07 for Carr Croft Care Home

This inspection was carried out on 12th September 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

Carr Croft Care Home 19/08/08

Carr Croft Care Home 21/02/08

Carr Croft Care Home 25/01/07

Carr Croft Care Home 03/08/06

Carr Croft Care Home 17/03/06

Carr Croft Care Home 13/12/05

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Carr Croft Care Home Stainbeck Lane Leeds West Yorkshire LS7 2PS Lead Inspector Catherine Paling Unannounced Inspection 12th September 2007 09:40 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 Carr Croft Care Home DS0000066259.V350481.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. Carr Croft Care Home DS0000066259.V350481.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carr Croft Care Home Address Stainbeck Lane Leeds West Yorkshire LS7 2PS 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) 0113 2782220 F/P 0113 2782220 Carrcroft Care Home Limited Ms Jacqueline Waters Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Carr Croft Care Home DS0000066259.V350481.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To provide accommodation for one named service user in the category DE(E) 25th January 2007 Date of last inspection Brief Description of the Service: Carr Croft is a large converted Victorian house, providing personal care for up to 35 older people of either sex. Nursing care is not provided and the community nursing service gives support for any nursing needs that can be managed at the home. The garden area to the front has had some landscaping following completion of the extension. Residents have access to this area. Accommodation is provided in single and shared rooms. Some of the shared rooms have en-suite facilities, as do the new bedrooms in the extension. Communal areas are on the ground floor, with a large lounge/dining area; a smokers’ lounge and other seating areas. The home is situated close to the local amenities of Meanwood. Current charges range from £400 to £480. Additional charges are made for chiropody, hairdressing, daily papers, toiletries, some activities and transport. Escorts are charged at £7.50 per hour. This information was provided by the home at the inspection of September 2007. Information about the services is provided by the home in the form of a Statement of Purpose and Service User Guide. Carr Croft Care Home DS0000066259.V350481.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit by one inspector who was at the home from 09.40 until 16.35 on 12th September 2007 and from 09.30 until 16.40 on 13th September 2007. As part of the inspection process an ‘expert by experience’ was at also the home on the 13th September from 10.20 until 15.00. An ‘expert by experience’ is a person who has experience of using a service. Because of this they can help an inspector get a picture of what it is like to live in the home. They produce written information for the inspector some of which is included in this report. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live there and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. A number of documents were looked at during the visit and all areas of the home used by the people who lived there were visited. A good proportion of time was spent talking with the people at the home as well as with the manager and the staff. An Annual Quality Assurance Assessment (AQAA) had been completed by the home before the visit to provide additional information. This is a selfassessment of the service provided. Survey forms were sent to the home prior to the inspection for the manager to distribute providing the opportunity for people at the home; visitors and healthcare professionals visiting the home to comment, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. A number of surveys were returned and comments are included in the body of the report. What the service does well: People living at the home and their relatives spoke well of the care and support from staff. • ‘The home is a nice place to be. The staff are very kind’ • ‘There is a choice of good food’ • You can ‘laugh with the staff’ Carr Croft Care Home DS0000066259.V350481.R01.S.doc Version 5.2 Page 6 Visitors are welcomed into the home throughout the day and often take people out if they are able to go. People were happy at the home and one said ‘they are lovely here, nothing to grumble about’. There are some good fully assisted facilities in the recently completed extension. What has improved since the last inspection? What they could do better: People said that they were bored and the provision of stimulation and activity was poor. Some improvement was seen in some care records others were of a poor standard without enough information for staff. This means that care needs could be missed. During the course of the inspection several examples were seen of staff failing to respect the dignity of people at the home. These observations included people looking unkempt and wearing stained and creased clothing; a lack of respect for differing cultural backgrounds and people not having free access to their walking frames. There were not enough staff employed to properly look after the people at the home. This included care staff and people employed to carry out kitchen duties, domestic tasks and laundry duties. This means that there was a serious risk of care needs being overlooked and not met. Significant shortages of staff have been identifies on five separate occasions since December 2005. Following this visit a warning letter was sent to the provider regarding these issues. The CSCI is taking further legal advice and Carr Croft Care Home DS0000066259.V350481.R01.S.doc Version 5.2 Page 7 may take enforcement action as a result of continued breaches of the Care Homes Regulations. Further detail can be found in the body of the report and requirements and recommendations are at the end of the report. 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. Carr Croft Care Home DS0000066259.V350481.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 Carr Croft Care Home DS0000066259.V350481.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): 2 and 3 (Standard 6 does not apply to this service) People who use the service experience adequate quality outcomes in this area. Overall, people are provided with enough information to enable them to make an informed choice about the home. The admission process includes preadmission assessments and introductory visits where possible. We have made this judgment using available evidence including a visit to this service. EVIDENCE: Although not a key standard the decision was made to look at contracts as a result of comments received from a number of sources. Signed copies were seen of contracts for the majority of private clients, although a small number had not been signed and returned to the home. Copies of the local authority contract were also available. Following discussion the provider proposed to add the completion of the contract onto the admission checklist to make sure that these can be signed at the time of admission. The provider was also Carr Croft Care Home DS0000066259.V350481.R01.S.doc Version 5.2 Page 10 advised that when changes occur, such as the fee increases, contracts should be re-issued to make sure that people have up to date information. Information given in the AQAA stated that a detailed pre-admission assessment form is completed before people are admitted and that information is collected from a variety of sources. In the sample of records seen this was the case with Easy Care documents and the home’s own assessment documents available. People are welcome to spend time at the home before deciding whether to move in. There is a further assessment completed on admission at the home that follows the activities of daily living as a framework. However, although assessments did identify areas where staff support and understanding was needed there was little detail for staff. This means that some needs could be overlooked. For example, particular mental health problems, communication difficulties, religious and cultural needs. Carr Croft Care Home DS0000066259.V350481.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 People who use the service experience poor quality outcomes in this area. Care plans do not contain enough detailed information about individual needs. This means that there is a risk that care needs could be overlooked. People at the home are protected by safe medication practices. Staff practices compromise the dignity of the people at the home. We have made this judgment using available evidence including a visit to this service. EVIDENCE: Information in the AQAA said that ‘individual care plans are clear and detailed reducing the risks for care needs to be overlooked’. This was found not to be the case as the standard of recording was variable and there was a lack of specific detail to advise and support staff in knowing how to care for people. This means that there is a clear risk of care needs Carr Croft Care Home DS0000066259.V350481.R01.S.doc Version 5.2 Page 12 being overlooked particularly when there are few staff on duty and new staff are working unsupervised. The care of four people was case tracked (their care looked at in detail) and this included looking at their records. Although some improvement was seen the level of detail was not enough to make sure staff had enough information about care needs. For example, although there was a risk assessment for smoking for one person there was no information about whether this person was safe to smoke unsupervised or not; a risk of urine infections had been noted and there was instruction to ‘encourage fluids’ and to ‘monitor’ this person. There was no indication of how much fluid or how it was to be monitored. This person had a low weight and there was a dietary care plan in place. The instruction was that this person should have a ‘well balanced diet’ with no indication of what this meant, no suggestion of any dietary supplement or nutritious snacks and no mention of the fluids they were supposed to have. Care plans had not been updated to reflect changes and this could lead to confusion. There was also some out of date information about skin damage that had healed and the type of equipment in use. In the case of one person with some mental health needs there was no guidance for staff on how to deal with aspects of this condition. Daily records indicated that staff on occasions had to address some behavioural issues but there was no care plan in place to give guidance. One person had been at the home for about four months. There was very little information in the records and care plans were vague and unhelpful with no evaluation or update since they were written on admission. Daily records again indicated that there were some mental health issues with no information for staff on how to deal with these. This person was an insulin controlled diabetic and there was no information for staff on what to look for should their diabetic control become unstable. One person from a different cultural background. This person had been coming to the home for day care for almost a year until becoming a permanent resident. There had been no attempt to address communication issues or to help staff understand differing religious and cultural needs. Comments received in surveys were positive about the home saying ‘support is first class especially if one is not very well’ and ‘where a doctor is required the staff ensure that an appointment is made with the appropriate doctor’. Other information received by CSCI throughout the year has raised concerns about general care Information received from other healthcare professional raised concerns about some basic care needs. For example, people being left to sit in wet clothing following incontinence and instructions about care not always being followed. Carr Croft Care Home DS0000066259.V350481.R01.S.doc Version 5.2 Page 13 Observed medication practices were safe. The manager carries out spot checks on medication records and provides update for staff. The manager has medication update from the local pharmacist. Observation at the inspection was that the majority of people, particularly the women, looked unkempt. It was evident that they had not had their hair washed and had not seen a hairdresser recently. People were wearing stained and creased clothing. People were not changed after the lunchtime meal when they had split food down themselves. A member of the care staff was heard calling people by derogatory names rather than their proper name. During the course of the afternoon the inspector watched the manager change a leg dressing in the lounge with other people around. This was undignified. A significant number of people at the home were mobile with the use of walking frames. Once people were sat in chairs these walking aids were not left with the person but taken and stored together out of reach. This means that people were unable to mobilise freely. Shared rooms did not have privacy curtains in place. A warning letter has been sent to the provider raising concerns about the lack of respect for people’s dignity. Carr Croft Care Home DS0000066259.V350481.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): 12, 13, 14 and 15 People who use the service experience adequate quality outcomes in this area. There is a risk that religious and cultural needs of some people living at the home will not be met. People are supported in maintaining contact with their family and friends and visitors are welcomed at the home. People said that they do not have enough to occupy them through the day and that they were bored. We have made this judgment using available evidence including a visit to this service. EVIDENCE: Information in the AQAA states that the home ensures ‘that each individual’s social, cultural, recreational and occupational characteristics are maintained and met’. This was found not to be the case particularly in the case of people from different ethic and cultural backgrounds. Visitors are welcomed at the home at anytime throughout the day and people who are able go out regularly with their families. Carr Croft Care Home DS0000066259.V350481.R01.S.doc Version 5.2 Page 15 The provision of stimulation and activities for people living at the home is very limited with some people once again saying they were bored. The Expert by Experience also observed a lack of stimulation and many people ‘either asleep or staring into space’. At the lunchtime meal people were told that they could sit where they wanted by one member of staff. Another member of staff was heard to ask people to move and change places when they had been sat waiting for almost an hour. The current table arrangement is such that meals have to be passed over people to the opposite side of the table, as there is no room to pass between the wall and the table. It also means that people sat between the table and the wall had great difficulty in leaving the table during the meal to go to the toilet. Menu choice is given but people are asked what they would like for lunch for the following day. This means that many people cannot remember what they have ordered. Large jugs of juice were provided for people but as these were too heavy for people to lift they were reliant on staff for refills. It also appeared that there were not enough tumblers as some people had to wait some time to be offered a drink. Placemats were dirty and worn. The management of the mealtime was poor on the first day of the visit with some people being seated at the table for almost an hour before getting their lunch and the whole mealtime taking almost two hours. Comments from people suggested that this was not unusual – ‘looks like another late do’. The evening meal on the first day of the visit was also late. Most people enjoyed the food and it looked attractive when it was served. Comments received were positive with people saying that ‘The home is a nice place to be. The staff are very kind’. The Expert by Experience said that people ‘seem to like the home’ and that there was ‘affection for the residents shown by some of the staff’. However, it was also noted that other staff seemed ‘bored and unwilling’ and ‘disinterested’ appearing ‘mechanical in their treatment of the residents’. Carr Croft Care Home DS0000066259.V350481.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): 16 and 18 People who use the service experience good quality outcomes in this area. People living at the home are protected from abuse with the majority of staff aware of adult protection procedures. People feel safe at the home. A complaints procedure is available and, overall, people feel that any concerns will be taken seriously. We have made this judgment using available evidence including a visit to this service. EVIDENCE: Information in the AQAA stated that nine complaints had been received at the home none of which had been upheld. A complaints and compliments file is kept at the home. Records of complaints received were seen together with information about the investigation and outcome letters sent to complainants. Comments received suggest that people at the home and healthcare professionals are aware of the complaints procedure and most are confident that concerns will be dealt with. Responses included: • Complaints process – ‘explained by Mrs Waters when first went to Carr Croft’. DS0000066259.V350481.R01.S.doc Version 5.2 Page 17 Carr Croft Care Home • • ‘Any concerns we have, which have been very few, have been dealt with most satisfactorily’. ‘Concerns have been raised with the manager over a number of issues – some have been responded to, others not’. The manager provides safeguarding training to the staff. She is due to have her own training updated with the local authority within the next couple of months. Carr Croft Care Home DS0000066259.V350481.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): 19 and 26 People who use the service experience adequate quality outcomes in this area. Overall people live in a comfortable and safe environment. Staff practices put people at potential risk of cross infection. We have made this judgment using available evidence including a visit to this service. EVIDENCE: The home provides a comfortable and homely environment for people. There is easy access to the gardens at the front of the home, which provide an attractive outlook. The view from the back of the home remains unchanged with these areas needing landscaping so that people have an attractive outlook. There is a security issue with the front door being unlocked and people free to wander into the home without challenge. Carr Croft Care Home DS0000066259.V350481.R01.S.doc Version 5.2 Page 19 There were no permanent domestic staff employed. There was one person on work experience who was carrying out cleaning duties for the whole home unsupervised. Areas of the home were dirty. There was some poor practice regarding control of infection, which was shared with the manager at the visit. Several soap dispensers were empty and paper towels were not available throughout. Carr Croft Care Home DS0000066259.V350481.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): 27, 28, 29 and 30 People who use the service experience poor quality outcomes in this area. There are not enough staff with the right skills to make sure that the needs of the people at the home are met effectively and consistently. The inability to retain staff means that there is a lack of continuity for people living at the home. We have made this judgment using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA states that there are ‘appropriate staffing levels’ with ‘service user dependency taken into account’ and that ‘full induction is maintained’. This was not found to be the case at the inspection. The manager was on shift with four carers, on both days. After 14.00 there was three carers. They were supported by one domestic, who was on work experience and working unsupervised, and a cook who has been in post since June this year. Both these people finish their shifts between 14.00 and 15.00. This meant that after that time care staff were involved in the kitchen. Throughout the day carers are responsible for laundry cover. The person working in the kitchen was not a qualified cook and had no previous experience of running a kitchen catering for the frail elderly. There was no kitchen assistant and the manager had taught her some of her cooking skills. Carr Croft Care Home DS0000066259.V350481.R01.S.doc Version 5.2 Page 21 The third carer on the evening shift was a person working one shift before starting permanent work at the home. She was working in an unsupervised capacity. Care staff continue to be heavily involved in non-caring duties with not enough ancillary staff to support them in their caring role. The result of employing staff in insufficient numbers and without proper experience and skills is that the people living at the home are at potential risk of not having their needs met. Shortfalls in staffing levels including ancillary support has been identified on five previous occasions. Following a recruitment drive the staffing levels at the visit of January 2007 had improved but many of the staff in post at that time have since left. There seems to be a problem with the retention of staff on a long-term basis. The provider was not adhering to their own staffing proposals put forward in January 2007. The inability to retain staff means that there is a lack of continuity for people living at the home. A warning letter has been issued and legal advice is being sought by the CSCI regarding enforcement action. Carr Croft Care Home DS0000066259.V350481.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): 31, 33, 35 and 38 People who use the service experience poor quality outcomes in this area. The management of the home is not well organised and this results in some practices that do not promote and safeguard the health, safety and well being of people living at the home. We have made this judgment using available evidence including a visit to this service. EVIDENCE: The manager is a qualified nurse and maintains her registration with the Nursing and Midwifery Council (NMC) through regular update. However, regulation requires her to consult with the community nursing service where people at the home have nursing needs. She has yet to complete the registered managers’ award (RMA). Carr Croft Care Home DS0000066259.V350481.R01.S.doc Version 5.2 Page 23 The manager carries out a range of basic in-house audits to help monitor the service and facilities at the home. There was an action plan outlining action to be taken in response to the findings. For example, regular meetings had been set up with the community nurses to improve communication and to address issues around infection control; in response to the number of accidents at the home the manager had reviewed staff breaks and introduced half hourly checks on people and this has led to a reduction in the number of accidents. Satisfaction surveys are also carried out and include relatives, people at the home and staff. Overall responses were good although some questions around choice and respect had not been answered positively. Staff questionnaires gave positive responses, which were at odds with observation and discussion held with a number of the staff over the two days of this visit. The home does not act as appointee and only very small amount of people’s money is kept to pay for magazines, newspapers and other small items such as toiletries. Records were kept and were clear. Records are kept of any accidents occurring to people at the home. Accident reports were held in a file and were out of date order, which made auditing difficult. It would appear from records seen that not all accidents are being reported to CSCI as required under Regulation 37 of the Care Homes Regulations 2001. The manager has produced a basic audit to help her monitor the frequency of accidents. She has taken action to reduce the number of accidents but records show that most accidents happen after 14.00 hours when the number of staff on duty falls. Regular meetings are held with people at the home and notes are kept. Topics discussed include the food and outings. The provider visits the home on a regular basis and records these visits as required under Regulation 26 of the Care Home Regulations 2001. These reports are not sent to the CSCI. A formal request has been made for these reports to be sent to the CSCI every month. The manager has a commitment to safeguarding the best interests of the people at the home. However, the lack of sufficient staff and a stable workforce means that the ability to develop the services and facilities at the home is limited. Without regular administrative support and with a constantly changing staff group the manager is not always able to give priority to her managerial duties. Carr Croft Care Home DS0000066259.V350481.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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 1 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 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 1 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 2 Carr Croft Care Home DS0000066259.V350481.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement Care plans must be further developed to provide detail of the action, which needs to be taken by staff to ensure that all aspects of the health, personal and social care needs of people living at the home are met. This must also include cultural needs. This will make sure that staff have full details about people’s care needs so that they understand how to care for people effectively, and make sure that staff understand and can properly support people from different cultural backgrounds. The dignity of people living at 15/10/07 the home must be respected by: • Making sure that residents are changed out of stained clothing as soon as possible. • Employing dedicated laundry staff in order to make sure that clothes are laundered correctly and to a good standard. DS0000066259.V350481.R01.S.doc Version 5.2 Page 26 Timescale for action 30/10/07 2 OP10 12(4)(a)& (b) Carr Croft Care Home • • • Reviewing the current hairdressing provision to make sure that residents have their hair cared for properly. Making sure that residents with different cultural needs and who do not have English as their first language are supported in a way that preserves their dignity and respects their cultural and ethnic background. Making sure that staff are appropriately trained and directed to meet the needs of residents from other ethnic backgrounds and provide care that respects residents and preserves their dignity. This means that the dignity of people at the home will be preserved by means of them wearing clean, well laundered clothes, having their hair cared for properly so that they do not look unkempt and their dignity is preserved. People from different cultural and ethnic backgrounds will be properly supported and their dignity preserved. 3 OP12 OP13 16(m)(n) The provider must provide more opportunities for people to be occupied. This must include developing links with the local community and the opportunity for outings where appropriate. People at the home will not be bored and will have more stimulation and occupation. 14/01/08 Carr Croft Care Home DS0000066259.V350481.R01.S.doc Version 5.2 Page 27 4 OP27 18(1)(a) Timescale of 03/09/07 not met. There must be sufficient staff with the skills and experience, employed to meet the needs of people living at the home. This must include care staff, kitchen staff, domestic staff and laundry staff. This is to make sure that that there is proper provision for the health and welfare of people living at the home. Arrangements must be made to make sure that all designations of staff have received the training they need to meet the needs of the people living at the home. This is to make sure that that there is proper provision for the health and welfare of people living at the home. The provider must send monthly reports to CSCI of visits to the home. Monthly reports will help the CSCI to monitor the conduct of the home and progress in addressing identified shortfalls. The manager and provider must make sure that all the required notifications are made to the CSCI as required. The notification of death, illness and other events is required as part of ongoing monitoring of the conduct of the home. 15/10/07 5 OP30 18 12(1)(a) 14/01/08 6 OP33 26 & 37 15/10/07 Carr Croft Care Home DS0000066259.V350481.R01.S.doc Version 5.2 Page 28 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 OP14 Good Practice Recommendations The manager should make sure that staff understand the promotion of choice. For example, walking frames should be left within reach and people should be allowed to sit where they want to at mealtimes. The provider should review the suitability of the shared rooms for occupancy by two people. The manager should review the arrangements for the control of cross infection. This should include update for staff. 2 3 OP23 OP26 Carr Croft Care Home DS0000066259.V350481.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Carr Croft Care Home DS0000066259.V350481.R01.S.doc Version 5.2 Page 30 - 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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