Inspection on 27/10/05 for Croft House

This inspection was carried out on 27th October 2005.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Croft House 02/05/07

Croft House 15/11/06

Croft House 07/02/06

Croft House 30/11/04

Croft House 11/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Croft House 155 Town Street Horsforth Leeds West Yorkshire LS18 5BL Lead Inspector Linda Trenouth Unannounced Inspection 27th October 2005 9:15 Croft House DS0000001440.V258229.R01.S.doc Version 5.0 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 DS0000001440.V258229.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 Adults 18-65. 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 DS0000001440.V258229.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Croft House Address 155 Town Street Horsforth Leeds West Yorkshire LS18 5BL 0113 258 0131 0113 2580131 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) St Anne`s Community Services Mrs Diane Joan Barker Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Croft House DS0000001440.V258229.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2004 Brief Description of the Service: St. Anne’s Shelter and Housing Action own Croft House, which is a listed building. It provides accommodation and care, without nursing, for up to 7 residents with a learning disability. It is situated in a pleasant residential area in Horsforth, very close to shops, pubs, a library, a health clinic, GPs, a pharmacy and churches. The home is accessed easily by public transport and has parking for two cars, one of which is a designated disabled space. The home is spacious providing accommodation over two floors, with one bedroom on the ground floor and six on the first floor. There are gardens to the front and rear of the building, with outdoor seating. Croft House DS0000001440.V258229.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was the first inspection visit for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk. The last inspection of the home was on 30th November 2004. This was an unannounced inspection carried out by one inspector who was at the home from 09.15 until 15.30. The main purpose of this inspection was to make sure that the home continues to provide a good standard of care for the residents. The methods used at this inspection included looking at care records; observing working practices and talking to staff, residents and the manager. Comment cards were sent to the home to provide residents and visitors with the opportunity to comment on the service. What the service does well: The organisation provides good induction and ongoing training for the care staff at the home and is committed to ensuring all staff complete the NVQ award. The staff receive regular supervision and support from the deputy manager and manager of the home. Regular staff meetings take place and are recorded. The management and staff make sure that residents make meaningful decisions about their lives and take part in the day-to-day running of the home. Residents are provided with a large and varied range of day care, leisure activities and holidays. They have good opportunities for personal development and joining in the local community. The staff support individuals to be independent and to reach their full ability both in the home and in the community. Croft House DS0000001440.V258229.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 Croft House DS0000001440.V258229.R01.S.doc Version 5.0 Page 7 contacting your local CSCI office. Croft House DS0000001440.V258229.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Croft House DS0000001440.V258229.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. People are able to make an informed decision about the home from the written information they receive and what they see when they visit the home. Residents and their relatives are clear about their rights whilst living at the home, from the contract they are given. EVIDENCE: The information within the service user guide is helpful and informative. Each resident has their own copy of the information with a general copy available for relatives, visitors and new admissions. Clear pre-assessments are now undertaken on all prospective residents. The information is clearly detailed and records provide good detail of the trial period at the home. Croft House DS0000001440.V258229.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. Staff treat residents with dignity, helping them to make decisions in all aspects of their lives. Residents contribute and are involved with their personal goals and individual care plans. EVIDENCE: Staff were able to give examples and details of the individual care needs of the residents and talk about how these related to the residents I.P.P. or care plan. The records reviewed included risk assessments, care plan and monthly updates. The care plans are reviewed by the resident and the staff at regular intervals. Residents bedroom doors are all fitted with a lock and staff were seen to knock on bedroom doors before entering Croft House DS0000001440.V258229.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15 and 16. Residents are encouraged to join in social and leisure activities, to keep links with their friends and family and to exercise choice and control over their lives. EVIDENCE: Croft House DS0000001440.V258229.R01.S.doc Version 5.0 Page 12 Residents continue to be fully involved with the daily domestic routines in the home with staff help. Residents choose which tasks they wish to undertake. Residents are helped to clean their own bedrooms and they are encouraged to do their own laundry and help in the kitchen. One resident observed during the inspection was helping clean as part of their weekly plan. The staff are helpful and thoughtful in furthering the residents skills within the home. The staff provide a mixed and interesting programme of activities both within the home and wider community. Many of the residents regularly attend day centres and are able to use local college courses via their day centres or the homes staff will arrange these for them. Some of the residents were attending regular art and dance classes at their local colleges. The residents in the home are encouraged to be as independent as they can be and go out and be part of the local community. Staff explained that individuals are free to plan their own days, taking into account attendance at training centres. All are encouraged and supported to pursue their own hobbies and interests and staff explained that service user holidays are based around residents preferences and interests. Residents had been on holiday with the staff to a cottage in the Lake District. All residents took part in the activities in the local community, visiting local pubs, shops, swimming baths and places of interest and specialised activities such as Gateway, Pudsey Club and Faith and light. Croft House DS0000001440.V258229.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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 and 20. The residents physical and emotional needs are met, and they are supported in a way they prefer. Medicines are not safely administered in the home and the residents are vulnerable to potential harm from the inaccurate administration of medication. EVIDENCE: The care plan reflects the daily needs and strengths of the individual. The daily needs and strengths are assessed and put into an individual plan. GP’s and other healthcare professionals are regularly involved and their recommendations are put into place. The records clearly showed that each resident was always asked what they would like to do and assisted when and where they needed help. The administration of medication raised serious concerns, staff that were administering medication were not always the staff that signed the medication record. Medication must never be secondary dispensed for someone else to administer to the resident. The staff were not always making sure that the resident took the medication, and at times were failing to administer Croft House DS0000001440.V258229.R01.S.doc Version 5.0 Page 14 prescribed medication. The deputy manager has raised concerns of poor practice with staff but the errors continue. Staff must take responsibility in a professional manner for the administration of medication and be aware of their individual accountability and duty of care. All staff must receive training in the administration of rectal diazepam and the homes procedures followed. Staff must be competent and safe to administer all medications. The training must be regularly monitored and the practice agreed by the GP of the individual concerned. The home was not recording the disposal or returns of medication to the pharmacist. Croft House DS0000001440.V258229.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Residents views and concerns are listened to and acted upon. The home has complaints and adult protection procedures in place, which protect the residents. EVIDENCE: The complaints procedure is clear and easy for residents and relatives to follow. A copy is included in the Service User Guide. The registered manager said that she encourages people to voice their opinions and complain if they are unhappy. The organisation has developed a booklet for residents on adult abuse and how and when to report any incidence of abuse. The home has updated its adult protection information to comply with local authority guidelines. Croft House DS0000001440.V258229.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None. Not reviewed at this inspection. EVIDENCE: Croft House DS0000001440.V258229.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35 and 36. Residents are supported by well-supervised and competent staff that meet the needs of the residents at the home. The staff are experienced, well trained and know what they are doing. They have good relationships with the residents and care for them well. EVIDENCE: No new staff have been recruited since the last inspection. Staff have transferred from other homes within the St Annes organisation. Staff induction and training records were reviewed and provided evidence of the LDAF foundation training and the organisational on going commitment to the NVQ award. All staff are registered on the NVQ qualification. Both the manager and deputy manager are qualified to NVQ level 4. Staff had received other training in areas such as Autism awareness, Epilepsy, promotion of communication, promotion of equality and sexual orientation. All staff are issued with a copy of the General Social Care Council code of conduct and practice, and CRB (Criminal Record Bureau) checks are carried out. Croft House DS0000001440.V258229.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 and 43. The home is well managed and the interests of the residents are the main concern of the manager and staff. Record keeping, safety checks and systems of communication make sure that the home is a safe place to live. EVIDENCE: The manager is very experienced and has completed the Registered Manager’s Award. The record keeping in the home is good. The information about residents is clear and up to date including risk assessments, and regular safety checks are made on equipment and are recorded to make sure the building is safe. The home undertakes regular satisfaction surveys and receives positive thank you cards from relatives. The area manager supports the home by visiting regularly and provides a report of their findings. Croft House DS0000001440.V258229.R01.S.doc Version 5.0 Page 19 Night staffing at the home consists of one waking and one sleeping in member of staff. Consideration should be given to the safety of the lone worker through the night and how communication in an emergency will be maintained. It was recommended to the manager that consideration be given to some form of intercom or a mobile pager which alerts the second member of staff should assistance be needed during the night. Croft House DS0000001440.V258229.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Croft House Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 DS0000001440.V258229.R01.S.doc Version 5.0 Page 21 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 YA20 Regulation 13 Requirement Written permission needs to be sought from the GP to agree to the administration of rectal diazepam. Staff must be competent and adequately trained to administer this medication. The staff at the home must adhere to the Royal Pharmaceutical Societys Guidelines on the Administration and control of medicines in a care home. Timescale for action 30/01/06 2 YA20 13 30/01/06 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 YA42 Good Practice Recommendations An intercom or pager alert system should be considered to improve communication in an emergency through the night. Croft House DS0000001440.V258229.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Croft House DS0000001440.V258229.R01.S.doc Version 5.0 Page 23 - 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!