Inspection on 13/12/05 for Carr Croft Care Home

This inspection was carried out on 13th December 2005.

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 12/09/07

Carr Croft Care Home 25/01/07

Carr Croft Care Home 03/08/06

Carr Croft Care Home 17/03/06

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Larchfield Manor

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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 13th December 2005 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 Carr Croft Care Home DS0000066259.V267454.R01.S.doc Version 5.0 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.V267454.R01.S.doc Version 5.0 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 278220 0113 278220 Carrcroft Care Home Limited Care Home 18 Category(ies) of Past or present alcohol dependence (1), registration, with number Dementia - over 65 years of age (1), Old age, of places not falling within any other category (18) Carr Croft Care Home DS0000066259.V267454.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The places for DE(E) and A are specifically for the named service users Date of last inspection 08/03/05 Brief Description of the Service: Carr Croft is a large converted Victorian house, providing personal care for 24 service users over pensionable age. There are no restrictions with regard to sex or religion. There is a large attractive garden to the front of the house to which the service users have access, seating is provided on the patio area. The home is currently undergoing major building work to provide an extension to the home with the intention of increasing the number of registered places. Accommodation is currently provided in single and shared rooms, some of the shared rooms have en-suite facilities. Communal areas are on the ground floor, with three lounges and a dining room available. The home is situated close to the local amenities of Meanwood. Carr Croft Care Home DS0000066259.V267454.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) is required to carry out a minimum of two inspections of a care home in a twelve-month period and this was the third visit for the year 2005/06. The previous two visits were made in connection with the ongoing building works. This was an unannounced inspection carried out by one inspector who was at the home from 09.15 to 14.30. Reports of previous inspections are available at the home and can be accessed on the Internet at www.csci.org.uk The main purpose of this inspection was to make sure that the home provides a good standard of care for the service users and to assess progress on meeting any requirements and recommendations made at the last visit. The methods used at this inspection included a brief tour of the building; looking at case records and other documents; as well as talking to staff, service users and the manager. As part of the inspection process comment cards were provided to the home for service users and relatives. At the time of writing the report none had been returned. The building of the extension to the home continues and is nearing completion. What the service does well: What has improved since the last inspection? The home now has a permanent manager who provides clear guidance to staff. The pre-admission assessment is carried out to a good level providing detail of the care needs of prospective residents. Carr Croft Care Home DS0000066259.V267454.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Carr Croft Care Home DS0000066259.V267454.R01.S.doc Version 5.0 Page 7 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.V267454.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. (Standard 6 is not applicable) Residents have their needs fully assessed prior to admission to the home. EVIDENCE: All residents have their needs fully assessed prior to admission to the home. Those pre-admission assessments seen had been carried out to a good standard. Carr Croft Care Home DS0000066259.V267454.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9. Overall, residents care needs are met but this is not fully evidenced within the care plans. Residents are treated with respect and their privacy is respected. EVIDENCE: A sample of individual case files was looked at. There are two documents that appear to provide a similar level of information. One is called the ‘Resident care plan’ providing an overview of care needs but no detail; and the other is the ‘Initial plan of care’ that gives more detail based on the activities of daily living. From these two documents the care plans are developed to provide more detailed instructions for care staff about how specific care needs are met. For a resident admitted in August there was an ‘initial’ plan that addressed the issues of settling down at the home. This is good practice. One of the reasons for admission was poor nutrition. There was a nutritional risk assessment which had identified a low risk and was being reviewed monthly. The care plan gave instructions for the resident to be weighed weekly. This was not happening as the resident had refused to be weighed on several occasions. The care plan had not been updated. Other risk assessments such as mobility had not identified a risk but were being reviewed monthly. A risk was that this Carr Croft Care Home DS0000066259.V267454.R01.S.doc Version 5.0 Page 10 resident would go out of the home and possibly misuse alcohol. There were no instructions for staff on management of the possible recurrence of alcohol misuse. There was guidance on who to contact if he was away from the home for an agreed length of time. However there was no photograph. Rising and retiring times were noted in the care plan. Another resident needed more assistance from staff but care plans did not contain sufficient detail of what her needs are. For example, ‘ensure hygiene is maintained’ and ‘observe skin areas’ do not provide staff with clear guidance on how to meet the needs of the resident. Reviews were not meaningful. For example, reviews consisted of statements such as ‘to follow plan’. A review should indicate which parts of the plan have worked and which have not worked or need to be changed. There was written evidence of the involvement of other healthcare professionals. The manager has been carrying out regular audit of the drug administration systems. Some shortfalls were identified. These have been shared with staff and acted upon. The manager has changed the pharmacy arrangements and has provided training for the staff with regard to the new monitored dose system. The pharmacist has provided the home with written procedures about the system. Staff treat residents with respect. Privacy is also respected; one resident was seen with her own door key. A requirement has been made. Carr Croft Care Home DS0000066259.V267454.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15. The kitchen was reasonably well managed. Residents are offered a varied diet. EVIDENCE: There was no permanent cook employed at the home. A member of the care staff was providing cover for the kitchen with the deputy and manager providing additional cover. The kitchen was clean and tidy. There were fly nets at the windows but these were torn. The insectoflash was not switched on. At the time of the visit the dishwasher was broken and had been for about a week, staff were having to wash up by hand. The lunchtime meal included a choice of both main course and sweet. Records were kept of the food served. Temperature records were also kept and were available for inspection. Recommendations have been made. Carr Croft Care Home DS0000066259.V267454.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these standards were assessed. Carr Croft Care Home DS0000066259.V267454.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19. The building works was nearing completion and refurbishment of the original building has yet to be carried out. EVIDENCE: The building work was ongoing at the time of the inspection. The approach to the home is not clearly signposted but a ramp takes visitors to a side door. The staff were working under difficulties and there has obviously been a certain amount of disruption to both staff and residents. Residents appeared to be reasonably content and did not appear to be unduly distressed by the ongoing works, which are nearing completion. The refurbishment of the existing building has yet to be done. The building area inside the home was separated by a gate which could be accessed by some residents. Carr Croft Care Home DS0000066259.V267454.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Staffing levels were not sufficient to meet the needs of the residents. Satisfactory recruitment procedures protect residents. Staff receive training to enable them to look after the residents competently. EVIDENCE: The building work was ongoing at the home and the staff were working under some considerable difficulty. In addition there were a small number of residents who were particularly demanding of staff time. An immediate requirement notice was issued to the manager at the time of the inspection and telephone contact made with the provider to make sure that sufficient staff are provided to meet the need of the residents. There was no permanent cook and one carer was working her hours in the kitchen with the manager and deputy manager providing additional cover. One cleaner was employed for five days a week with limited weekend cover. Care staff currently have the responsibility for laundry with night staff doing some cleaning and ironing. The manager was asked to make sure that staff in the laundry could hear the call system. The manager said that there were about three care staff who have achieved their National Vocational Qualification in care at level 2 and some of these staff were keen to progress to NVQ level 3. NVQ training for the care staff is to recommence in spring 2006 via one of the local colleges. In addition to the care staff the cleaner is to also undertake her NVQ in housekeeping as part of the Carr Croft Care Home DS0000066259.V267454.R01.S.doc Version 5.0 Page 15 plan for her to take on further responsibilities when the additional beds are registered. The manager and deputy manager are enrolled on a course that will cover such topics as customer care, team leader responsibilities and supervisory care. The manager spoke of her intention to undertake training to enable her to provide fire training at the home. Another carer will become the in-house trainer for manual handling and moving. Adult protection training is planned for January 2006. New staff undertake induction and foundation training based on the TOPPS standards. Two personnel files were looked at of recently employed staff and overall the recruitment procedures were satisfactory and the appropriate checks were carried out. The only staff photographs were photocopies of passports and these were not clear. Requirements have been made. Carr Croft Care Home DS0000066259.V267454.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. The manager provides clear leadership to the staff. The interests of the residents are seen as important to the manager and her staff. Some practices at the home do not always ensure the health and safety of the residents. EVIDENCE: There is a new manager in post at the home. She has a nursing background and this is her first experience of managing a care home. She has yet to register on the Registered manager’s award (RMA) or to undertake her National Vocational Qualification in management at level 4. The CSCI has received and is processing the manager’s application to be registered as manager of the home. In the absence of a manager the quality assurance systems have not been fully implemented. There are some monitoring systems used by the manager. For example, there is a simple audit of accidents and incidents carried out by the manager. The total numbers of accidents are recorded and are then broken Carr Croft Care Home DS0000066259.V267454.R01.S.doc Version 5.0 Page 17 down into different time frames throughout the twenty-four hour period. In addition there was evidence that the manager is reviewing the recording of accidents and identifying omissions such as whether relatives have been informed. Notes were available of meetings held with residents and relatives. The most recent meeting was held on 24 November and the notes were not yet available. Since the manager took up post in July there have been three meetings with relatives. Topics discussed at these meetings included the provision of hairdressing; when the optician and chiropodist would be coming to the home and mealtimes. The home has a policy of not handling residents’ monies. However, some the personal allowances kept in the homes safe. Records were seen and were clear of all transactions and receipts kept. One signature was recorded and it was recommended that two be recorded for all transactions. Access to the safe is restricted. A gate restricted the access to the internal building works. One resident with mental health problems had been able to access this area on more than one occasion. A requirement and recommendation have been made. Carr Croft Care Home DS0000066259.V267454.R01.S.doc Version 5.0 Page 18 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 X 3 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 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X X X 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 2 2 2 X 3 2 X 2 Carr Croft Care Home DS0000066259.V267454.R01.S.doc Version 5.0 Page 19 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 set out in detail the action, which needs to be taken by staff to ensure that all aspects of the health, personal and social care needs of the service users are met. The plan must be drawn up with the involvement of the service user, recorded in a style accessible to the service user; agreed and signed by the service user whenever capable and/or their representative. The care plans must be reviewed at least monthly. 2 OP27 18 Adequate staffing levels must be maintained at all times as required immediately following the inspection. Monitoring systems must be in place to ensure that ancillary staffing levels remain adequate. 3 OP28 18 NVQ training must continue for care staff to ensure that the target of 50 trained members of care staff is reached by the DS0000066259.V267454.R01.S.doc Timescale for action 31/03/06 14/12/05 31/12/05 Carr Croft Care Home Version 5.0 Page 20 end of 2005. 4 OP33 24 31/03/06 Effective quality assurance and quality monitoring systems, based on seeking the views of service users, must be implemented to measure success in meeting the aims, objectives and the statement of purpose of the home. Policies and procedures must be reviewed to ensure staff have access to relevant and accurate information. (previous timescale of 1/04/05 not met) 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 OP15 Good Practice Recommendations The fly nets at the kitchen windows should be repaired and the insectoflash kept switched on. All equipment in the kitchen should be maintained in full working order. Two signatures should be recorded for all transactions involving residents’ personal allowances. 2 OP35 Carr Croft Care Home DS0000066259.V267454.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Carr Croft Care Home DS0000066259.V267454.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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