CARE HOMES FOR OLDER PEOPLE
Croft Avenue Residential Home Wordsworth Street Penrith Cumbria CA11 7RJ Lead Inspector
Cath Wilson Unannounced 31 August and 2 September 2005 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 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 Avenue Residential Home F58 F10 s22547 croft avenue v234434 310805 ui stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Croft Avenue Residential Home Address Wordsworth Street Penrith Cumbria CA11 7RJ 01768 867155 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Care First Care Homes Ltd (BUPA Care Services) Ms Denise Shearer Care Home 40 Category(ies) of OP - Old Age registration, with number DE(E) - Dementia, over 65 of places Croft Avenue Residential Home F58 F10 s22547 croft avenue v234434 310805 ui stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for a maximum of 40 service users to include: up to 40 service users in the category of OP (Older people) up to 4 service users in the category of DE(E) (Dementia over 65 years of age) 2. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 24 January 2005 Brief Description of the Service: Croft Avenue is a care home registered to provide care for forty older adults. The home is owned and run by BUPA Care Homes. The home is located in a quiet residential area of Penrith and is approximately half a mile from the town centre and local facilities and amenities. Accommodation is offered on the ground and first floors, there are three sitting rooms, two dining rooms, a treatment room, general offices, kitchen and laundry on site. The home has a passenger lift and a stair lift for access to one area of the home. A call bell system is operational throughout the home. There are well-attended garden areas of the home and car parking is available to the front of the home. Croft Avenue Residential Home F58 F10 s22547 croft avenue v234434 310805 ui stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out during periods of two days. During the interview the inspector met with residents, the registered manager and care staff. A tour of the premises both inside and out took place and staff and care records were assessed. What the service does well: What has improved since the last inspection?
Arrangements are in place for the decoration and furnishings to be upgraded and renewed as needed and the requirement from the previous inspection has been implemented. Croft Avenue Residential Home F58 F10 s22547 croft avenue v234434 310805 ui stage 4.doc Version 1.40 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 Avenue Residential Home F58 F10 s22547 croft avenue v234434 310805 ui stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Croft Avenue Residential Home F58 F10 s22547 croft avenue v234434 310805 ui stage 4.doc Version 1.40 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 standard(s) These standards were not assessed on this unannounced inspection. EVIDENCE: Croft Avenue Residential Home F58 F10 s22547 croft avenue v234434 310805 ui stage 4.doc Version 1.40 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 standard(s) 7, 8 and 9 People’s personal and health care needs are attended to in a way that promotes their privacy and dignity. The medication system is very well managed promoting good health care. EVIDENCE: People in the home have a care plan that details their care needs. There are some care plans that are in need of updating. The manager has identified these and a programme is underway to make sure that these accurately reflect people’s needs in an up-to-date manner. This must be maintained in a progressive manner so that staff are fully informed of any changes that may occur. Health care needs are detailed and the medication system is securely stored and very well organised. Staff are trained in the home’s systems and only designated staff administer medicines to people in the home. District Nurses and G.P’s visited the home as needed and residents have access to all of the usual primary health care services. From the evidence provided during the inspection people are cared for in a caring, nurturing and supportive manner. People spoke kindly about the care they received and were comfortable and at ease with the staff and manager. Croft Avenue Residential Home F58 F10 s22547 croft avenue v234434 310805 ui stage 4.doc Version 1.40 Page 10 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 standard(s) 12, 13 and 14 Resident’s family and friends are encouraged to visit the home and do so in a relaxed and welcoming environment. People are encouraged and supported to make their own choices about there day-to-day lives. EVIDENCE: People informed the inspector how they made their own choices about what they did and decided how they were going to spend their time. If something was not how they liked it they can talk to the manager and staff about it and are at ease doing so. People are actively included in the way the home is organised and there is a stimulating and varied range of interests to be involved with which is overseen by the activities organiser. People’s cultural and religious wishes are observed. Family and friends visit regularly and they can meet with people in the communal areas or in the privacy of their own room. Croft Avenue Residential Home F58 F10 s22547 croft avenue v234434 310805 ui stage 4.doc Version 1.40 Page 11 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 standard(s) 16 The home has a satisfactory complaints procedure that is available to people in the home and their relatives. EVIDENCE: The home has a suitable complaints procedure and residents are provided with information about how to complain on admission to the home. Croft Avenue Residential Home F58 F10 s22547 croft avenue v234434 310805 ui stage 4.doc Version 1.40 Page 12 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 standard(s) 19, 20, 21, 22 and 26 People are provided with safe, comfortable and relaxing surroundings that include specialist facilities and adaptations. EVIDENCE: There is a plan in place to maintain the furnishings and fittings and this is time-scaled for completion. Carpet areas have been upgraded and the arrangements to replace the window furnishings has been organised. People are very comfortable with their own rooms and ‘wouldn’t have it any other way’. The home has a range of specialist equipment to assist people’s independence and appropriately placed call bells. The garden areas are attractively maintained with seating and shaded areas. The home throughout is clean and pleasant. Croft Avenue Residential Home F58 F10 s22547 croft avenue v234434 310805 ui stage 4.doc Version 1.40 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 30 People in the home benefit from receiving support from a staff group who are provided with training opportunities to meet people’s comprehensive needs. EVIDENCE: The manager and staff are informed of people’s care needs. This will be enhanced by all care plans being kept up-to-date and regularly monitored so that staff are fully informed of people’s current needs. People were very complimentary about both the manager and staff and about the ‘kindly’ way they were attended to. Staff in the home are ‘so caring’ and one person said they are ‘little treasures’ in the way ‘they look after me’. Care staff are involved in a training programme that provides them with the skills and abilities to meet the needs of residents and to carry out their duties safely. Croft Avenue Residential Home F58 F10 s22547 croft avenue v234434 310805 ui stage 4.doc Version 1.40 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37 and 38 There are satisfactory systems in place to ensure the home operates in a way that protects the health and safety of residents. People’s views and opinions are listened to and acted upon. EVIDENCE: Procedures are in place to gain the views and opinions of residents about the services provided and people are confident their views are heard. Care staff had not been receiving regular supervision. There is, however, a programme now in place to achieve this and staff that met with the inspector confirmed that this had now started to be implemented. The records assessed are confidentially maintained. The arrangements now in place to monitor the care plans regularly will enhance the home’s care practices so that people’s current needs are accurately reflected. The tests and checks of the fire safety equipment and procedures were being completed as required.
Croft Avenue Residential Home F58 F10 s22547 croft avenue v234434 310805 ui stage 4.doc Version 1.40 Page 15 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 x
COMPLAINTS AND PROTECTION 3 3 3 3 x x x x STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 3 x x 2 2 3 Croft Avenue Residential Home F58 F10 s22547 croft avenue v234434 310805 ui stage 4.doc Version 1.40 Page 16 No Are there any outstanding requirements from the last inspection? 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 Regulation Requirement Timescale for action 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 Good Practice Recommendations Croft Avenue Residential Home F58 F10 s22547 croft avenue v234434 310805 ui stage 4.doc Version 1.40 Page 17 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith, Cumbria CA11 9BP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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