Inspection on 08/03/06 for Croft Acres

This inspection was carried out on 8th March 2006.

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

Croft Acres 01/10/08

Croft Acres 10/10/06

Croft Acres 01/07/05

Croft Acres 01/02/05

Croft Acres 04/05/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

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 Croft Acres 15 Hibberd Road Malin Bridge Sheffield South Yorkshire S6 4RE Lead Inspector Debbie Foster Unannounced Inspection 8th March 2006 08:20a 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 Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 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. Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Croft Acres Address 15 Hibberd Road Malin Bridge Sheffield South Yorkshire S6 4RE 0114 234 0016 0114 231 6729 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) Croft Acres Limited Karen Anne Walker Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st July 2005 Brief Description of the Service: Croft Acres is a care home providing personal care. Accommodation is provided for 24 residents. The home is privately owned by Mrs Pamela Bradshaw and is situated in a residential area not far from Hillsborough centre. There is good access to public transport and services/shops and amenities are close by. The home is purpose built with accommodation provided on two floors, which are accessed by a lift. Residents accommodation is provided in 24 single rooms. There is a lounge on each floor and two dining rooms on the ground floor. The home is served by a central kitchen and laundry. Sufficient bathing facilities are provided. There is a car park at the front of the home surrounded by raised flowerbeds. Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over one day. The manager, 5 staff, and 8 service users spoke with the inspector during this time. Aspects of certain records were checked. Interaction between the staff and the service users was observed. Aspects of the environment were inspected. The inspection started at 08:20 a.m. until 15:40 p.m. Feedback on the inspection was given to the manager. What the service does well: What has improved since the last inspection? The new manager and staff team had implemented the majority of the requirements made on the last inspection to improve the service. The manager was not routinely used to cover care staff shortages, which gave her time to implement strategies that would improve the day-to-day management of the home. Mandatory training had been arranged and provided for a number of staff to safeguard the residents and develop the staff team. Consultation with residents and relatives had taken place. There were regular residents meetings. Their comments on food and the menu were being actioned. Questionnaires on the quality of the service had been undertaken and a summary of the results was available. In the main service users and their relatives were satisfied with the care at the home. Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 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. Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 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 Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 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): 1, 3, 4 & 5. Prospective residents had the information they needed to make an informed choice about whether they wished to live at the home prior to moving in. Resident’s needs were assessed before moving into the home to ensure the service could meet their needs. Information provided and the detail of services offered assisted the residents and their representative to know that their needs could be met by the home prior to admission. Residents and the relatives had the opportunity to visit and assess the quality and facilities of the home to determine its suitability prior to admission. EVIDENCE: The requirements made on the last inspection were checked only for these standards. Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 9 The service user guide was accompanied by a summary of the quality surveys undertaken by service users and relatives about what they thought about the care and the service they received at the home. This gave information to prospective residents on what was good about the service and areas for improvement. In the main the comments received were positive. The new manager had revised the homes assessment tool to include all the elements of standard 3.3 to assist in the assessment process and ensure any prospective new residents needs could be met by the home. Staff said that the manager assessed all new residents before introductory visits to the home. The manager said that other professionals had been reassessed a number of residents since the last inspection to ensure their needs could be met by the home. One resident had needed to move to ensure his/her care needs could be met. Requests for reassessment had been made for other residents and were still to take place. The records seen confirmed this. Residents confirmed they had visited the home for a look around and have tea prior to making the decision to live there. Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 10 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 & 10. In the main the service users health, personal and social care needs were set out in individual plans of care to ensure service users receive the care they need. Some omissions were found. The administration and storage arrangements for Medication were satisfactory to meet the needs of service users. Errors were found in the administration of some medication to ensure all health needs of some service users were met in full. Service users were treated with respect and their right to privacy was upheld. EVIDENCE: The requirements made at the last inspection were checked for standards 7,8, 9 & 10. Resident said that the staff attended to their personal care needs and medical assistance provided when needed. They said that they were happy with the care they received. Staff were “kind” and “ patient”. Staff explained how they Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 11 met and attended to the personal care needs of service users and how and when health care check up’s and G.P. appointments were arranged. The service user plans checked recorded the majority of personal care and health needs. All sections within the care plan had been completed. However, there were still omissions, specific detail for example on the frequency of care for continence routines, how to undertake a task and the detail of monitoring and the supervision required for a resident with mobility problems. Although staff explained this was carried out at regular intervals. Care plans had been signed by the resident and or representative. The daily notes did not always reflect the service user individual plan of the care given. Risk assessment on falls had been completed and reviewed in the last few months on the two case files checked. There had been improvement in the care planning records however further development was needed. Six resident’s medication records sheets checked. Medication was in stock. A further two items of medication was checked in more detail and in the main was being administered as prescribed by the GP. Medication was securely stored. There were monitoring of the medication system taking place and records kept. Since the last inspection the home had changed the pharmacist used and the administration system in place. Medication of a resident who was self administering was securely stored and monitored. The resident concerned had a current risk assessment for self administering her/his own medication. Staff said that only the senior care staff and manager administer medication to the residents. The records confirmed they had received training in this area. However, medication, which was recorded as being refused by the residents constantly, had not been reviewed. One item of medication did not have specific administration instructions for the staff to follow “ as directed”. The residents said that the staff were polite and helpful when attending to their personal care and these duties were carried out in private. The staff were able to explain how they would respect the service users privacy. They were seen knocking on bedrooms doors and waiting before entering. Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 12 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): 13, 14 & 15. Resident were able to maintain contact with families and friends and visitors to the home are made welcome. There turnover of staff had stabilized, which had ensured residents were more settled and felt they had control over who was caring for them in the home. In the main the meals at the home offered choices, including healthy options to promote a healthy eating and a balanced diet for the service users. However, residents wanted some changes to the meals on offer. EVIDENCE: The requirements made at the last inspection were checked for standards 13, 14 & 15. Residents said that they were able to keep contact with family and friends and some had their own telephones installed in their room. The residents said their visitors were always made welcome when they visited. Residents spoken to said that the turnover of staff had settled down since the last inspection. Staff said the majority of vacancies had now been recruited to. Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 13 They were working well together and establishing good teamwork. A number of residents commented that they were happy living at the home. Residents said in the main the quality of food served was good and that “there was always a choice”. Menus offered a choice of food at each mealtime. Residents said that they enjoyed their breakfast. Drinks were taken around the home in between meals and a resident said that “ if you wished for one in between then staff would always get you one”. The meal times were unhurried and a relaxed atmosphere was noted. Some residents said that the menus would benefit from being reviewed at lunchtime and tea times. These issues had been raised at the recent residents meeting and the manager said these were being addressed with the new cook. Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 14 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): 16 & 18. Complaints were acted upon ensuring service users were listened to. However, the recordings systems had omissions. Service users were protected from abuse by the awareness of staff through training and the homes procedures. EVIDENCE: Staff and some residents said they knew how to complain. A complaints procedure was displayed in the home. Two residents said that if they had any concerns that they would talk to the manager and felt any issues would be addressed. There had been three formal complaints made since the time of the last inspection. The home did have a recording system for complaints. However, they did not always fully record of the investiagtion process and the outcome of the complaint or if the complainant was satisfied with the outcome. The staff interviewed said they had received adult protection training and the records checked confirmed this. The home had a adult protection policy and procedure. Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 15 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, 22 & 26. Service users live in a well-maintained environment to ensure their safety and comfort. Service users have the specialist equipment to meet their needs and promote independence. Staff were aware of hygiene procedures. The home was clean to ensure a pleasant environment for the service users. However, training on infection control had not been given to all staff. EVIDENCE: The home was clean, well maintained, furnished and decorated to a good standard to ensure a pleasant environment for the service users. Since the last inspection the hoist that was rusty in parts had been replaced. Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 16 Residents said that they were comfortable; the home was always clean and tidy. Bed linen was changed regularly and their clothing laundered appropriately. The home had policies and procedures on infection control and the staff wore protective clothing when required. However, not all staff had received training in infection control. The manager said she was in the process of arranging this. Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 17 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 & 30. The staffing levels were sufficient to meet the full needs of the service users. The home was pursuing NVQ training for staff without the qualification to ensure they would be fully competent in their work and could provide appropriate care to the service users. In the main the recruitment information obtained for staff was sufficient and met the required standard to adequately protect the welfare of residents who lived at the home. Omissions were found. Staff were not fully trained to do their job to ensure they could meet the needs of service users in all areas. EVIDENCE: The staffing levels met the minimum staffing agreement set with the Commission for Social Care inspection from the staff on duty on the day of the unannounced inspection and the rotas checked. The following staff were on duty, the manager, one senior carer, two carers, domestic and a cook on the morning shift. Three care staff were to work the evening shift and two waking night staff. Staff and some service users said they felt that the staffing levels were sufficient. Staff were seen sat chatting with service users at different times of the day. The manager was not routinely working and included in the care staff rota. The manager said she would be working the occasional shift to Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 18 ensure she was aware and monitoring work practices once she had a full staff compliment, which would be in the next month. Staff said they did have training opportunities and care workers were undertaking NVQ training. This was confirmed in the records checked. The home had not yet achieved the target set of 50 for its work force to achieve this qualification, however they were well on target to achieve this in the near future. The recruitment information obtained for staff in the main met the required standard. Two out of three staff files checked contained two references including one from the staff member’s last employer. The manager said all staff had Criminal Record Bureau (CRB) checks this corresponded with the files checked. Omissions were found which included references from one file, employment history from one file and gaps in employment history not explained. The manager said that full recruitment checks had been carried out for all staff recruited whilst she had been in post. Since the last inspection the manager had arranged a number of mandatory training courses for existing staff. Staff said they undertaken the majority of mandatory training (e.g. health and safety, fire, moving and handling, personal care, adult protection and first aid). The records checked confirmed this. However, for staff commencing work in the last few months and one-day induction had been given, no other training had been provided. The manager said she did not have a budget for training her staff although she was pursuing training organisations to assist in this area. Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 19 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): 33, 35, 36 & 38. Effective quality assurance systems were not fully in place to pick up on all omissions and mistakes. Although a number of areas were audited to ensure the home is running in the best interest of the service users. In the main the home had systems in place to safeguard the financial interests of the service users they were supporting by recording transactions and holding receipts. Staff were not being formally supervised at the frequency specified in the Regulations and Standards to ensure individual staff development and the monitoring of care practices. In the main the health, safety and welfare of service users and staff were promoted and protection was in place. Some mandatory training for staff had not been provided in full to ensure service users safety at all times. Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 20 EVIDENCE: Effective quality assurance systems were not fully in place to pick up on all omissions and mistakes. These are reported on in other sections of this report. The manager had been developing this area further since the last inspection. A number of areas were audited to ensure the home is running in the best interest of the service users. The registered provider had been undertaking monthly visits to the home and a written report had been produced for these. In the main these covered the areas required but more direct detail on how the service was operating was needed. The frequency of formal staff supervision had improved since the last inspection. However, not all staff were not being formally supervised at the frequency specified in the Regulations and Standards to ensure individual staff development and the monitoring of care practices. The registered providers son said that the home handled a number residents personal allowances. Three records were checked, there were income and expenditure recorded and receipts were kept. Monies were securely stored. One service user said he could access his money when he wanted it and could spend it on what they liked. Other service users were supported to handle their money. Staff undertook shopping for them. The home liaised with relatives on the spending of service users money were appropriate. The new manager had not been involved in this area so far since being in post and needed to be fully aware of practices in line with her role, duties and responsibilities. The accounts were not externally audited. Aspects of Safe Working Practices were checked on this inspection. Staff interviewed said they had received fire instruction training in the last six months. Fire evacuation/drills had taken place since the last inspection. Residents risk assessments had been reviewed. Omissions were found in the training of some staff have already been commented on in other areas of the report. Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 3 3 x 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 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 x x 3 x x x 2 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x 2 2 x 2 Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 22 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 15,17, 43 Schedule 3 Requirement Individual care plans must contain specific information on the staff action required to ensure identified needs are met. The previous timescale given for action to be taken of 1 May 2005 was not met. Medication refused by the resident and which is not being adminsitered as prescribed by the GP must be reviewed. Medication administration instructions must be specific for the staff to administer accurately and safely to the residents. A review of the meals on offer within the menu must take place and appropriate action taken to implement the proposals made by the residents. The details of investigations and the outcome of complaints must be recorded. Along with the details of whether the complainant is satisfied with the outcome of the complaints. All staff must receive training on infection control. A review of all staff recruitment DS0000002951.V284585.R01.S.doc Timescale for action 28/06/06 2 OP9OP8 12,13 & 43 28/04/06 3 OP15 12 & 16 28/04/06 4 OP16 22 28/04/06 5 6 OP26 OP29 13 & 16 18,43, 28/05/06 28/03/06 Page 23 Croft Acres Version 5.1 schedule 2 7 OP38OP30 18 & 43 8 OP33 24 & 43 9 OP35 12 & 17 schedule 4 18 & 43 10 OP36 files must take place and omissions rectified. Work assessment must be put in place for employee who have worked for the home a long term,where getting the last employers reference would not be possible. The must be sufficient funding to ensure staff are trained in all areas specfic to their role and duties to meet the needs of the residents. Staff must receive all mandatory training including; Personal care Food hygiene First aid Fire Adult protection Moving and handling. The quality assurance system must be developed further to ensure the best interests of the service users, and that aims and objectives are met. The monthly written report undertaken by the registered provider must include all areas stipulated in Regulation 26 of the Care Homes Regulations 2002. The manager must monitor the resident’s finances. The resident’s accounts must be externally audited. Care staff must receive supervision at least 5 times a year. This must cover all aspects of care, philosophy of the home and career development needs of the staff. The previous timescale given of 1 May 2005 for action to be taken had not been met. 28/05/06 28/06/06 28/05/06 28/04/06 Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 24 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 OP28 Good Practice Recommendations Plans should be put in place to ensure that 50 of care staff are quaslified to NVQ level 2 by 2005. Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Croft Acres DS0000002951.V284585.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!