Inspection on 25/01/07 for Carr Croft Care Home

This inspection was carried out on 25th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

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 03/08/06

Carr Croft Care Home 17/03/06

Carr Croft Care Home 13/12/05

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Snydale Care Home

Larchfield Manor

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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 Key Unannounced Inspection 25th January 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Carr Croft Care Home DS0000066259.V321199.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.V321199.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 0113 2782220 Carrcroft Care Home Limited Ms Jacqueline Waters Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Carr Croft Care Home DS0000066259.V321199.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd August 2006 Brief Description of the Service: Carr Croft is a large converted Victorian house, providing personal care for up to 28 service users of either sex over the age of 65. The garden area to the front has had some landscaping following completion of the extension. Residents have access to this area. The number of registered places at the home has recently increased with the completion of the building works. These were carried out to a good standard. Refurbishment of the existing building has to be finished before the final increase in the number of registered beds is granted. 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 £375 for local authority funded placements to between £390 and £460 for privately funded residents. Additional charges are made for chiropody, hairdressing, daily papers, toiletries, some activities and transport. This information was provided by the home in July 2006. 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.V321199.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way care services are inspected. They are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example, Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate”, and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes and copies of past inspection reports are available on our website – www.csci.org.uk Information about the home is gathered from a variety of sources, one being a site visit. Additional site visits may be made that will concentrate on specific areas such as health care or nutrition called random inspections. A random inspection of this service was carried out on 6 July 2006 to assess progress in the final part of the refurbishment programme at the home. A number of requirements were made following that visit. Two inspectors carried out the first key inspection of 2006/07 on 3rd August 2006. An inspector and regulation manager made a further visit on 16th August 2006. This second key inspection was carried out by two inspectors on 25th January 2007 who were at the home from 09.40 to 17.00. This second key inspection was to inspect all the key standards, (the key standards are identified in the main body of the report); to assess progress in meeting the requirements made following the previous inspections and to assess how the needs of people living in the home are being met. The methods used at the inspection included looking at care records, talking to residents, observing care practices in the home, talking to staff and management, looking at the environment and looking at other paperwork including staff and maintenance records. The home provided some information to the CSCI in advance of the inspection. Comment cards were left at the home for residents and their relatives. None had been returned at the time of writing the report. Carr Croft Care Home DS0000066259.V321199.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The manager must undertake formal management training as soon as possible to equip her to continue to develop the services at the home. The care plans have improved but there is still work to do to make sure that they detail fully the individual needs of residents. The quality assurance systems must be further developed to make sure that they assist the manager and provider to effectively monitor the service and facilities at the home. Carr Croft Care Home DS0000066259.V321199.R01.S.doc Version 5.2 Page 7 Although the provision of activities has improved several residents said that there was not enough to do and there were no outings. This area needs to be developed so that residents do not feel bored and get the opportunity to go out into the community and on longer trips. Further information can be found in the body of the report. Requirements and recommendations appear 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.V321199.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.V321199.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. (Standard 6 does not apply to this service) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Written information is now available to prospective residents and their families to help them to make an informed choice whether the home can meet their needs. Residents are encouraged to visit the home before they are admitted to help them decide whether to move in. The home is not registered to meet the needs of residents with dementia or mental health needs and there is a risk that their requirements will not be met. EVIDENCE: There is a detailed statement of purpose and a service user guide available to give current and prospective residents information about the services provided at the home. The service user guide needed some update to make sure that the information was accurate and up to date. Carr Croft Care Home DS0000066259.V321199.R01.S.doc Version 5.2 Page 10 All residents said they had been to look round the home before they decided to move in. Some said they had looked at other homes but decided on this one due to its welcoming atmosphere and cleanliness. One resident said, ‘it was absolutely lovely and spotlessly clean’. A visiting relative also said that her Mum and other members of the family had visited the home and had a meeting with the home manager before their Mum moved in. Most residents said they had been given information leaflets on the home before moving in. Pre-admission assessments had been carried out by the home for newly admitted residents. Social workers and care managers had assessed other residents, with the home then carrying out their own assessment from this. The assessment document could be used better in that more detail could be added. For example, one resident’s assessment said the resident had mental health problems but did not specify what the actual problems were. This lack of detail in the assessment process could lead to important care needs being overlooked. This resident did not have a care plan in place regarding their mental health needs, it appeared to have been overlooked. A number of residents had been identified at the previous inspection as having mental health needs. The manager had arranged for assessment by the relevant healthcare professionals. As a result the provider needs to apply for a variation in the conditions of registration at the home for three specific residents as agreed at the inspection. The manager must make sure that the home’s own pre-admission assessment procedures allow her to be sure that she does not admit residents to the home with mental health problems. Residents could not remember if they had been given a contract from the home, detailing the charges and services provided. The owner of the home said these had been completed but were not kept at the home. Residents must also have a copy of these agreements, so they know what they are being charged. Carr Croft Care Home DS0000066259.V321199.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans have improved and now contain more detailed information about individual needs, reducing the risks for care needs to be overlooked. Overall, medication practices are safe. Residents are treated with respect and their privacy is also respected. EVIDENCE: All residents spoken with said they could see a doctor if needed and that staff are prompt in arranging this. A visiting District Nurse said there was good communication between the home and the community nursing service and that they worked well together to meet the health needs of residents. She also said that staff are always willing to assist in attending to residents and that she finds them helpful and welcoming. A visitor to the home said that her relative’s physical and mental health had improved greatly since moving into the home. Carr Croft Care Home DS0000066259.V321199.R01.S.doc Version 5.2 Page 12 Another resident said that the staff had helped them get through depression. They said, ‘staff have been very helpful and very nice’. Care plans showed improvements from the previous inspection. Staff who were fairly new to the home said they had seen an improvement with the care plans and now found them useful with regard to residents’ needs. However, there is still work to be done to make sure residents’ needs are properly met. For example, one care plan on bathing said ‘needs help’; another care plan on safety said ‘needs to be looked after’ and a care plan on continence said ‘regular toileting’. A good care plan should give clear and detailed information on how and when care is to be delivered, with particular reference to the resident’s individual preferences and choices. The information would also benefit from a more person centred, individual approach to care planning. Despite the gaps in care planning documentation, staff were aware of the residents’ needs and made sure they were properly met. Residents looked well cared for. Some care plans had been written for residents when they had no need of support. An example of this was a communication care plan for a resident who had no difficulty with communication. In other cases care plans had not been produced to detail specific needs, for example, pain management for one resident and how to manage mental health problems for another. Staff had acknowledged cultural diversity but information within records lacked the detail that staff would find helpful in meeting specific cultural needs. Care plans are evaluated monthly. However, this is not detailed and does not show how an evaluation has taken place or what has been evaluated. Daily notes on the whole, tend to be rather repetitive with the use of the same phrases. For example, ‘no concerns’, ‘no problem’. This does not accurately describe care given to residents or give any indication of how they are. Some risk assessments gave reasonably detailed information on the management of risk. However, one resident was using pressure-relieving equipment, yet had no risk assessment completed for the risk of pressure sores. The manager said this resident’s needs had changed and she was no longer at high risk. This needs to be reflected in the care plan and risk assessment. Healthcare professionals were detailed in some individual resident contacts list. However, some had been overlooked, for example, one resident who sees a consultant psychiatrist had no contact details listed in their personal file. General Practitioner (GP) visits were documented for most residents, with details of any treatment ordered. Carr Croft Care Home DS0000066259.V321199.R01.S.doc Version 5.2 Page 13 Nutritional assessments had been carried out for residents who are nutritionally at risk. A member of staff who was giving out medication left the medicine trolley unlocked and unattended. This observation had been made at a previous inspection. A copy of the guidance for the administration and control of medicines in care homes, produced by the Royal Pharmaceutical Society was left at the home. A new drugs trolley has been provided and the local pharmacist provided some training in October. All staff must have regular medication update no matter what their previous experience is. One resident was concerned that a shared room did not have a lock on the door. This had been mentioned to the manager and arrangements were being made for the resident to have a single room, which would give them more privacy. Staff respect the privacy and dignity of the residents. Carr Croft Care Home DS0000066259.V321199.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to make choices about their day-to-day lives and are supported in maintaining contact with their family and friends. Visitors are welcomed at the home. Residents said that they do not have enough to occupy them through the day. The arrangement for the provision of activities and outings needs to be improved. Residents are provided with a varied and nutritious diet. EVIDENCE: The home has recently employed an activities co-ordinator for four hours per week. A church service takes place once per month, with a local Church of England vicar and some volunteers from the church. In addition to this, a lady visits the home twice per month to do activities such as exercise and carpet bowls. Carr Croft Care Home DS0000066259.V321199.R01.S.doc Version 5.2 Page 15 A number of residents said they wished there was more activity in the home. A couple of residents said they would like a little job in the home such as dusting to keep them busy. Some residents said they would like to go out in the community more but there are not enough staff to take them. Staff said trips can be arranged and the manager said that all residents were registered with the Access Bus. One resident was disappointed that trips to the coast had not taken place, even though this was discussed at a resident’s meeting last year. The resident also said that further meetings had been promised but had not happened. The manager said she had plans to re-start these meetings. A relative visiting the home said she had noticed an increase in activity recently. A couple of resident said how nice it was that the owners of the home always brought a big birthday cake in for any residents’ birthday. Most residents spoke highly of the food at the home. One said, ‘it is very good, better than most restaurants I have ever been to’. Another resident said ‘I have my likes and dislikes but there is always a choice’. There are two choices for each meal. Residents said they could ask for something different if they did not like what was on the menu. A visiting relative said, ‘the dinners are marvellous’. One resident said the meals were not always to their taste and would like the opportunity of discussing this with the chef. However, the chef’s post is currently vacant. The owner of the home is recruiting and hopes to make an appointment. This resident was looking forward to the planned residents’ meeting and a new chef starting. One of the carers and a part-time kitchen assistant are doing the cooking at the moment with the manager also occasionally providing cover for the kitchen. All residents were happy with the way they can make choices on a daily basis. One said, ‘you can do what you want when you want, have a bath or shower whenever you want one’. Another said ‘I like it here because you can please yourself’. Someone else said ‘its absolutely fantastic here’. Residents were seen being offered choices throughout the day. For example, whether to attend the church service, what to eat or drink and what activity to get involved in. Carr Croft Care Home DS0000066259.V321199.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected from abuse with the majority of staff aware of adult protection procedures. Residents feel safe at the home. A complaints procedure is available for all residents and they feel that any concerns will be taken seriously. EVIDENCE: There is a complaints procedure in place at the home and this is made available to residents and their families. Many residents said they had never had to complain about anything but would know how to if they needed to. The complaints procedure was displayed on the notice board in the hallway. One resident said, ‘if anything is wrong you can just talk it over with the staff or manager’. A record is kept of any complaints received and indicates that complaints are taken seriously and dealt with properly. The manager has had adult protection training and most staff have now been trained in the protection of vulnerable adults. The staff were clear about what they would do if they suspected any abuse or had an allegation made to them. Carr Croft Care Home DS0000066259.V321199.R01.S.doc Version 5.2 Page 17 The manager consults appropriately with the adult protection unit for advice and will involve independent advocates for residents, if necessary. Carr Croft Care Home DS0000066259.V321199.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, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable, safe and well maintained environment. EVIDENCE: Since the last inspection a great deal of work has been carried out to complete the required work to both improve and make safe the environment. The fire safety officer’s report has been actioned and the work was almost completed and an external fire escape has been fitted to the first floor of the new extension. Requirements made by the environmental health officer have also been met. The laundry area has been refurbished and new equipment provided. There were risk assessments in place for work practices in the laundry. Carr Croft Care Home DS0000066259.V321199.R01.S.doc Version 5.2 Page 19 The refurbishment programme of the whole home was very nearly complete with the last few curtains being replaced. The provider has also sought advice in the décor of the large lounge to make it more ‘homely’. Some pictures had been put up and had already improved the room. All residents said they were happy with their own rooms. Many of them described them as ‘beautiful’. Residents and relatives said the home was always spotlessly clean. Domestic staff had a good understanding of infection control and could describe the measures in place to prevent the spread of infection. Some of the care staff, however, did not wear protective clothing when serving food. The home was comfortably warm with none of the radiators too hot to touch. There have not been any problems with the hot water supply since the last inspection. Some rooms did not have lockable storage for residents to safeguard their valuables and the manager should make sure that this is available to all residents. Carr Croft Care Home DS0000066259.V321199.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff are sufficient to meet the needs of the residents. Staff have the skills to effectively meet the needs of the residents. The recruitment procedures are safe and ensure that residents are protected. EVIDENCE: Staff did not seem to have much time for sitting talking or doing an activity with residents. This was particularly apparent in the morning. However, in the afternoon some staff were able to join in with a quiz with residents. Recruitment records were looked at and overall satisfactory procedures were being followed. However, some staff did not have a photograph on file and some references had not been followed up by telephone calls or had an explanation on file of who had given them. There were a mixture of new staff and staff who have worked at the home for some time. All felt that their training needs were met and felt they were equipped to do their job. The home is now using the common induction standards for care for all new starters and these were being completed to a good standard. Carr Croft Care Home DS0000066259.V321199.R01.S.doc Version 5.2 Page 21 The home has an annual training plan and the manager has a system to make sure that all staff have training update as required. Much of this information was handwritten and not as organised as it could be. Some training had been done around the specific needs’ of residents. This included training on the management of challenging behaviour and dementia. All the care staff are expected to undertake a National Vocational Qualification (NVQ) in care at level 2. This training is now well established and the target of 50 trained to level 2 should be achieved later this year. Some care staff are also keen to move on to NVQ level 3. Carr Croft Care Home DS0000066259.V321199.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is reasonably well organised and results in practices that promote and safeguard the health, safety and well being of the residents. EVIDENCE: The manager is a qualified nurse and maintains her registration with the Nursing and Midwifery Council (NMC) through regular update. Although regulation requires her to consult with the community nursing service where residents have nursing needs her knowledge and experience is useful when liaising with other healthcare professionals. Carr Croft Care Home DS0000066259.V321199.R01.S.doc Version 5.2 Page 23 The manager has applied to do the Registered Managers Award but has yet to have confirmation of the start date for the course. Since the last inspection the manager and the provider have worked hard together to address the shortfalls identified at previous inspections. The manager now feels that after recent staff changes she has good support from the care staff as well as the provider enabling her to development the management systems at the home. The manager has developed a whole range of basic in-house audits to help her monitor the service and facilities at the home. Satisfaction surveys are also carried out but the manager needs to make sure that the results of these are made available in a timely fashion. The results of the survey conducted in the early part of 2006 are not yet available. A visitor to the home said that they found the home much better organised recently and staff seem to know what they are doing. Another visitor commented on the improved atmosphere in the home and better management. Staff also said they felt they got good support from the manager. The manager welcomes the input and involvement from residents’ families and friends. One relative said they feel very much part of their relative’s care. Records showed that residents and relatives had signed the care plans. The majority of residents and/or their families handle their own finances. Since the last inspection the manager has reduced her responsibility for handling any residents’ monies and residents and/or their families are invoiced for additional services such as hairdressing and chiropody. Records are kept of any resident accidents and the manager has identified that the standard of recording can be variable. A new accident report format has been developed and should provide a more consistent standard of information. There are maintenance systems in place for the fire safety systems and the manager sought the advice of the fire safety officer in the development of the fire safety risk assessment. Carr Croft Care Home DS0000066259.V321199.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 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Carr Croft Care Home DS0000066259.V321199.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 RQN Regulation Care Standards Act 2000 Section 15 15 Requirement Timescale for action 31/03/07 2 OP7 3 OP9 13 The provider must apply for a variation to the conditions of registration for the residents with mental health needs as identified at the inspection. Care plans must be further 30/10/07 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 the service users are met. This must also include cultural needs. The registered manager must 02/04/07 make sure that all staff are aware of the medication policies and procedures and follow them. Particular attention must be paid to the safe storage of medication and locking medication in the drugs trolley when it is left unattended. The provider must provide more opportunities for residents to be occupied. This must include developing links with the local community and the opportunity for outings where appropriate. DS0000066259.V321199.R01.S.doc 4 OP13 16 03/09/07 Carr Croft Care Home Version 5.2 Page 26 5 OP28 18 6 7 OP31 OP33 9 24 NVQ training must continue for care staff to ensure that the target of 50 trained members of care staff is reached by the end of 2006. The manager must obtain a relevant management qualification. The manager must continue to develop the quality assurance systems. Results of surveys must be made available promptly and systems must be in place to communicate effectively with residents on a regular basis. 30/09/07 31/12/07 02/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP2 OP23 Good Practice Recommendations Copies of contracts for residents should be available at the home for inspection. The provider should review the suitability of the shared rooms for occupancy by two residents. Carr Croft Care Home DS0000066259.V321199.R01.S.doc Version 5.2 Page 27 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. 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