CARE HOMES FOR OLDER PEOPLE
Croft House 26 Kirkham Road Freckleton Preston Lancashire PR4 1HT Lead Inspector
Mrs Lillian McMullen Unannounced Inspection 21st November 2005 10:30 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 Croft House DS0000063015.V260362.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. Croft House DS0000063015.V260362.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Croft House Address 26 Kirkham Road Freckleton Preston Lancashire PR4 1HT 01772 633981 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) Ammram Limited Mrs Janet Margaret Finn Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Croft House DS0000063015.V260362.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The home is registered for a maximum of 22 service users: Up to 22 service users in the category of OP (Older People) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 16th May 2005 Date of last inspection Brief Description of the Service: Croft House Care home provides residential care for up to 22 older people. It is situated in the village of Freckleton, which is close to the city of Preston. Leisure amenities are close by as well as local shops and public transport system. The home is on two floors and there a chair lift is in place. There are a number of aids and adaptations in place throughout the care home suitable for the age range and needs of residents living there. There are twenty single rooms and one double room at present only one bedroom has en suite facilities. Croft House DS0000063015.V260362.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of five hours. At the time of the inspection there was 19 residents living at the home. The Pharmacy Inspector accompanied the lead inspector and carried out a full inspection of the medication procedures. As is normal usual practice, a separate letter will be been sent to the homeowner with the outcome of the pharmacist inspection. Prior to this inspection, resident and relative comment cards provided by the Commission For Social Care Inspection was sent to the home for completion. At the time of writing this report no completed comment cards have been returned. The inspector spoke with six residents, three staff, the registered manager and the homeowners. Documentation in respect of complaints, protection, resident’s finances and medication records were viewed. What the service does well:
This is a care home where residents are well looked after. The staff team work well together and show a good understanding of the needs of the people living at the home. Those residents spoken to said they liked living at the home and felt they were being well cared for by the staff. Routines within the home are flexible so that the people who live there can enjoy the lifestyle of their choice. Residents are encouraged to have their say and help make decisions about the running of the home. The atmosphere in the home is welcoming, relaxed and friendly. The new homeowners demonstrate a commitment to learning about the care of older people and are keen to play an active part in supporting the registered manager in providing a quality service. The staffing levels are good and a recent recruitment drive has been successfully resulting in a full staff group now being in post. The home operates to a good standard with a clear management structure both internally and externally. Good policies and procedures are in place, which are regularly reviewed. A quality assurance system is in place that has recently been reviewed by The Residential and Domiciliary Benchmark and the manager and staff are confident that they will retain the five stars awarded at last year. Croft House DS0000063015.V260362.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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 House DS0000063015.V260362.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 Croft House DS0000063015.V260362.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): EVIDENCE: None of the above standards were assessed at this inspection. Croft House DS0000063015.V260362.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): 9 Medication procedures need to be more robust to ensure residents receive their medication as prescribed. EVIDENCE: The Pharmacy Inspector carried out a full audit of the medication procedures. This resulted in a number of requirements and recommendations being made. As is usual practice, a separate letter will be been sent to the homeowner and registered manager with the outcome of the pharmacist inspection. Croft House DS0000063015.V260362.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: All the above standards were assessed at the previous inspection. Croft House DS0000063015.V260362.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 Arrangements for handling complaints are in place and concerns are responded to appropriately. The procedure in respect of the protection of vulnerable adults should be reviewed to ensure it complies with local protocols. EVIDENCE: The home has a comprehensive complaints procedure, which is contained in the Service User Guide and provided to residents and their relatives upon admission. The home has received no complaints since the last inspection. The Commission for Social Care Inspection has received no complaints within the last year and there have been no vulnerable adult referrals to Social Services. The complaint policy and procedure ensures that complaints would be responded to within 28 days. A system of recording all concerns is in place, which, are considered ‘non conformities’, the documentation in place allows for details of the complaint, the investigation and the outcome to be recorded. The residents living at the home, spoken to by the inspector, all responded that they are able to voice their views and know who to speak to if they are unhappy about any aspect of their care. The home has an abuse policy in place, which includes guidance on whistle blowing, abuse by residents and advice for staff regarding challenging behaviour. This policy is easily accessible by staff. However from observation of these documents it was noted that the procedure for the protection of vulnerable adults was not compliant with the D.O.H. guidance as stated in ‘No
Croft House DS0000063015.V260362.R01.S.doc Version 5.0 Page 12 Secrets’. The homeowner and registered manager was informed that once any suspicion or allegation of abuse has been reported to Social Services under no circumstances must an internal investigation be conducted until a strategy has been agreed by all lead agencies. The inspector also advised that all staff must receive training in the protection of vulnerable adults. Croft House DS0000063015.V260362.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): EVIDENCE: All the above standards were assessed at the previous inspection. However the homeowner discussed plans for an extension, which he hopes will commence early in the new year. Assurance was also given that refurbishment of the existing property will also take place. Croft House DS0000063015.V260362.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): 28 The home has good arrangements for staff training. EVIDENCE: Staffing levels at the Croft House reflect the needs and requirements of the service users accommodated. Since the previous inspection the staffing has remained unchanged with no new staff appointments. It is pleasing to note that the number of staff that has successfully completed a nationally recognised qualification in care at NVQ level 2 or above has increased. Out of the thirteen care staff employed seven members have gained this award and four further members of staff are near completion. Additional training is offered, at present a consultant has been appointed who is arranging training in a number of mandatory subjects. The inspector advised that all staff must be provided with training in all mandatory subjects and suggested that a training matrix be devised in order to track the training undertaken and provide information when refresher courses are due. The home’s recruitment procedure has been reviewed and the registered manager now ensures that no new members of staff commence employment without a satisfactory Criminal Record Bureau clearance having been received. Croft House DS0000063015.V260362.R01.S.doc Version 5.0 Page 15 Documents examined revealed that induction training is provided to all newly appointed staff. Whilst this training appears comprehensive in detail the inspector advised the registered manager to cross reference the current induction-training programme with the ‘Skills For Care’ induction standards. Croft House DS0000063015.V260362.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): 35 and 38 (in part) Resident’s finances are protected. Risk assessments need to be put into place for all safe working practices. EVIDENCE: The registered manager encourages all residents to be as independent as possible. Currently pensions are drawn on behalf of three residents and some personal monies are retained in the office for safekeeping. Examination of the records revealed that all expenditure is recorded with receipts attached. The inspector discussed the need to have risk assessments in place for all areas that could be a potential hazard, in particular all safe working practices. The inspector advised that a critical view should be taken of the whole environment and risk assessments developed that should then be read and signed by the whole staff group.
Croft House DS0000063015.V260362.R01.S.doc Version 5.0 Page 17 The registered manager was asked to forward the pre inspection questionnaire in order that evidence can be obtained that all equipment is service and maintained as required. Croft House DS0000063015.V260362.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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 X 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Croft House DS0000063015.V260362.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No 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. 2. 3. Standard OP9 OP38 OP18 Regulation 18 17 19 Requirement Medication procedures require reviewing. Risk assessments for all safe working practices must be in place. The procedure for the protection of vulnerable adults must be reviewed to reflect the correct protocol. Timescale for action 31/12/05 31/12/05 30/11/05 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. 3. Refer to Standard OP28 OP19 OP28 Good Practice Recommendations A training matrix should be implemented. A refurbishment programme should be implemented. 50 of the staff should be qualified to at least NVQ level 2 Croft House DS0000063015.V260362.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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