Inspection on 07/02/06 for Croft House

This inspection was carried out on 7th February 2006.

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 1 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 27/10/05

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 7th February 2006 10:00 Croft House DS0000001440.V281732.R01.S.doc Version 5.1 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.V281732.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 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.V281732.R01.S.doc Version 5.1 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.V281732.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2005 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.V281732.R01.S.doc Version 5.1 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 second 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 the 27th October 2005. There have been no additional visits made to the home since the last inspection. This was an unannounced inspection carried out by one inspector who was at the home from 12.00 until 16.30. 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, reviewing the environment and talking to the manager and staff. Comment cards were left at the home to provide residents and visitors with the opportunity to comment on the service. Feedback from the comment cards are included in this report. Feedback of the requirement and recommendation were given to the registered manager at the end of the visit. Requirements and recommendations made during this visit can be found at the end of the report. What the service does well: The home continues to provide a warm and comfortable environment for the residents and there is an ongoing programme of refurbishment and renewal. Croft House DS0000001440.V281732.R01.S.doc Version 5.1 Page 6 The organisation continues to provide a good and varied range of day care, leisure activities and holidays for the residents at the home. They have good opportunities for personal development and joining in the local community. The staff continue to support individuals to be independent and to reach their full ability. 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. The home has a clear service user guide, contract and complaints procedure and takes a responsible approach in the management of residents money. Relatives confirmed that they felt that they were made welcome at the home; they were informed of important matters relating to their relative and were satisfied with the overall care. Relatives comments included, I think my relative is well cared for. He couldnt be happier. The staff do a good job. What has improved since the last inspection? The home continues to make improvements and all requirements highlighted in the last inspection report have been addressed. The home has reviewed the practice of invasive medical practice at the home in light of health and safety procedures. The recording and administration of medication has improved. The manager has introduced a mobile intercom/ pager to improve communication between the night staff at the home. Croft House DS0000001440.V281732.R01.S.doc Version 5.1 Page 7 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 DS0000001440.V281732.R01.S.doc Version 5.1 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.V281732.R01.S.doc Version 5.1 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): 5. Each resident has a written contract ensuring that his or her rights are protected whilst living at the home. EVIDENCE: The residents have contracts outlining their terms of conditions whilst living at the home. The contract lists any additional charges that are made in addition to the fees for instance each resident contributes towards the lease vehicle for the home. Croft House DS0000001440.V281732.R01.S.doc Version 5.1 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): 10. Residents know that information about them is handled appropriately and that confidences are kept. EVIDENCE: Information is stored appropriately in a confidential area on the first floor of the home. There are lockable filing cabinets and cupboards storing confidential information. The induction training includes sharing of information and respecting confidentiality. All staff have access to the homes policies and procedures which include confidentiality and the use of information. Croft House DS0000001440.V281732.R01.S.doc Version 5.1 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): Not reviewed EVIDENCE: Croft House DS0000001440.V281732.R01.S.doc Version 5.1 Page 12 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): 18, 19, 20 and 21. The physical and emotional needs of residents are handled with respect and with dignity. Individuals are supported with their medication and safe systems are in place for the administration of medication. EVIDENCE: The staff regularly review the individual care plans and the way in that they could best meet the needs of the resident both now and in the future. General health needs were regularly monitored and the staff at the home continually reviewed the well being of residents. The staff continue to ensure that the residents independence and dignity is always maintained. Relatives confirmed that they were well informed regarding any changes to their relatives care and opportunities to meet privately with their relative or staff were always provided. Croft House DS0000001440.V281732.R01.S.doc Version 5.1 Page 13 The records and administration of medication had improved since the last inspection and it was noted that there had been no further errors occurring. The staff and the pharmacist are now completing the drugs return book. The management have taken the decision that staff will not administer rectal diazepam to residents at the home. All other medication is continuing as normal and the medication training via Protocol is continuing for all staff. Croft House DS0000001440.V281732.R01.S.doc Version 5.1 Page 14 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. The home has robust procedures for the management of residents personal money to ensure that the residents are protected from financial abuse. The home has complaints and adult protection procedures in place, which protect the residents. EVIDENCE: The contract between the residents and the home outlines what the fees cover and additional charges that will be made. All personal allowances are recorded and any purchases made on behalf of residents are recorded in the financial documents. Residents have access to their personal money at all times. The financial accounts are checked daily by staff and audited by the manager. The residents are encouraged to save for expensive items and holidays and have building society accounts for this purpose. The complaints procedure is clear and easy for residents and relatives to follow. A copy is included in the Service User Guide. The 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 concerns. Croft House DS0000001440.V281732.R01.S.doc Version 5.1 Page 15 Relatives confirmed that they could approach the staff and manager and were aware of the complaints process in the home. Croft House DS0000001440.V281732.R01.S.doc Version 5.1 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): 24, 25, 26, 27, 28, 29 and 30. The residents live in a homely, comfortable environment. Their bedrooms are appropriate to their needs and reflect their individuality. The home is appeared clean and well maintained, however hygiene practices may need to be reviewed in light of infection control. EVIDENCE: The communal areas of the home were in good order and well maintained. Residents bedrooms that were seen were comfortable and decorated individually reflecting different their tastes and personalities. The heating and lighting levels in all bedrooms seen were found to be good. Bathrooms and toilets generally were clean and tidy; however concerns were expressed regarding the accessibility of aprons and gloves for staff. Lighting to the toilets and bathrooms also needed review as the pulley switches had been placed out of reach and therefore residents were not able to use them. One toilet door lock also needed adjustment to ensure residents could use this and ensure adequate privacy. The toilets and bathrooms were clean and well maintained. Croft House DS0000001440.V281732.R01.S.doc Version 5.1 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 and 34. The staff have good induction and foundation training and comprehensive further training to meet the specialist needs of the residents. Whilst the organisation does not meet the training targets for NVQ it is committed to provide the training and four staff are completing their NVQ level 2. The staffing levels are good Monday to Friday but reduce at the weekends limiting activities and choices of residents at the home. EVIDENCE: Discussion with new staff confirmed that induction training and foundation training are undertaken. The monitoring of new staff is also put into place with regular reviews of their care practice. All staff train in the management of moderate challenging behaviour to meet the needs of residents at the home. Other staff training includes, first aid, food hygiene, adult protection, promoting equality, diversity and rights, Autistic Spectrum Disorder, communication, Epilepsy and Sexual Orientation. Croft House DS0000001440.V281732.R01.S.doc Version 5.1 Page 18 The comment cards from relatives were positive and relatives felt that generally the staffing levels were good at the home with the exception of the weekends where the staffing levels reduced. This limited the opportunities and choices for residents to participate in activities beyond the home. The manager felt that generous staffing hours were put in to supporting other times within the week when residents needed support from staff. It was agreed that the staffing levels did generally ensure a good range and quality of experience throughout the week and the manager would review the weekend staffing levels to see if adjustments could be made. Croft House DS0000001440.V281732.R01.S.doc Version 5.1 Page 19 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): Not reviewed. EVIDENCE: Croft House DS0000001440.V281732.R01.S.doc Version 5.1 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 Standard No Score 1 x 2 x 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 x x x x x x x Croft House DS0000001440.V281732.R01.S.doc Version 5.1 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 YA30 Regulation 23 Requirement The staff must access gloves, aprons easily to ensure that there is adequate management of hygiene and control of infection. The light pulleys must be in easy reach for everyone and the lock to the toilet door repaired. Timescale for action 01/05/06 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 YA32 Good Practice Recommendations The staffing levels fall over the weekends and limit the choices that residents can reasonably make to undertake activities. This should be reviewed to support residents over seven days period. Croft House DS0000001440.V281732.R01.S.doc Version 5.1 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.V281732.R01.S.doc Version 5.1 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. 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