Inspection on 08/07/08 for Croft House

This inspection was carried out on 8th July 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Croft House 11/07/06

Croft House 13/09/05

Croft House 10/05/05

Croft House 06/10/04

Croft House 06/04/04

Croft House 02/05/03

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Croft House Redlands Lane Fareham Hampshire PO14 1EY Lead Inspector Laurie Stride Unannounced Inspection 8th July 2008 10:15 Croft House DS0000033288.V367391.R01.S.doc Version 5.2 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 DS0000033288.V367391.R01.S.doc Version 5.2 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 DS0000033288.V367391.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Croft House Address Redlands Lane Fareham Hampshire PO14 1EY 01329 280600 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) Hampshire County Council Ms Helen Bradshaw Care Home 12 Category(ies) of Learning disability (0) registration, with number of places Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 12. Date of last inspection 11th July 2006 Brief Description of the Service: Croft House is a Hampshire County Council Home for adults with learning disabilities aged 18-65. The home is divided into four separate units. There are two main units for five service users and two units for more independent living or more intensive support. These can each accommodate one service user. The home is a short distance from Fareham town centre with nearby access to public transport. The primary reason for care is learning disability but some service users may have additional needs. Emergency admissions may occur, which can lead to the home reducing its respite service at times. The home may also become involved in longer-term care whilst waiting for alternative accommodation to be provided. Care plans are prepared with service users and relatives. The home has a sensory room, computer equipment, and a garden. The current range of fees is £5.11 - £7.52 per night, for people who are assessed as not paying the full client contribution. The current weekly fee including the full contribution is £756.00. Funding for any additional support need is referred through Adult Services. This information was obtained at the time of the inspection visit. Members of the public may wish to obtain more up-to-date information from the care home. Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This unannounced visit took place as part of a key inspection of this service. The visit lasted approximately four hours during which, we (the commission), spoke with three of the people who use the service, a person’s relative, two members of staff and the registered manager. Survey questionnaires were also sent as part of this inspection. At the time of writing this report, no returned questionnaires had been received. We also looked at samples of the records kept in the home and undertook a brief tour of the communal areas of the premises. Further evidence used in this report was obtained from the home’s annual quality assurance assessment (AQAA) and the previous inspection report. What the service does well: What has improved since the last inspection? The service has improved the ways that information is presented, such as the terms and conditions of residence, the complaints procedure and charter of rights, care plans and risk assessments. This makes the information easier to understand. After asking what people who use the service think about how the home is run, the service has developed individual activity charts. This helps to make sure that planned and unplanned activities take place for people who come to stay. Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 6 All people who use the service are able to keep their medication in their rooms. This supports people’s independence. The house has been fully re-decorated and new furniture has been provided. There are better records kept of the checks on new members of staff before they start work. This is so that the home can demonstrate that people who use the service are protected. 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. The summary of this inspection report can be made available in other formats on request. Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 7 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 DS0000033288.V367391.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 & 5 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The service makes sure that people who are interested in using the service have all the information they need to decide if the service will meet their needs. There are effective systems for making sure that people’s needs and aspirations are assessed prior to receiving a service. EVIDENCE: The service’s annual quality assurance assessment (AQAA) states that all new referrals have to be submitted with a full Care Management Assessment, and prior to any admission the service will complete their own in-house assessments and care plans, which will then be updated and amended as needs change or become more apparent. All people who use the service are provided with an information pack upon introduction to the service. They are supported with a yearly home visit, where the terms and conditions are signed and the Statement of Purpose and Business Plan is discussed for the coming year. The AQAA told us that Croft House also has a process where individuals are invited to participate in a departure assessment, which will attempt to ascertain their views and opinions of their stay, whilst it is fresh in their minds. Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 9 During this visit we looked at a sample of two individual’s files in relation to the initial assessment of their needs prior to admission. These contained details of the assessment and care planning to meet people’s needs, which are written in an accessible and easy-to-read format. We also saw that the service has developed new picture format versions of the Terms and Conditions of residence and the Charter of Rights. This shows that the service is actively working to assist people who use the service to understand their rights and responsibilities and how the service operates. Each person who stays at the home is allocated a key-worker, who works with the person and/or their representative in developing the care plan. Croft House DS0000033288.V367391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 & 9 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who use the service and their representatives benefit through being involved in making decisions and playing an active role in planning the care and support they receive. EVIDENCE: The service’s annual quality assurance assessment (AQAA) told us that care plans and risk assessments are completed in conjunction with the people who use the service, their parents/carers and other professionals. All plans are reviewed on a regular basis, especially after each stay, to ascertain if any changes need to be made to the plan, care and support the individual requires. For people who stay longer at Croft House, reviews are held with the person’s care manager and we saw evidence of this in the sample of records we looked at. Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 11 The sample of two care plans we saw provided clear information about people’s needs and wishes and guidance for staff when supporting the individuals. This included sections relating to any cultural and religious needs, communication, physical and emotional wellbeing. Before a person known to the service comes to stay, a designated staff member telephones the individuals’ relatives or representatives to ask if there have been any changes in relation to the care plan. There are specific ‘add-on’ sections that are used for this, such as health, moving and handling and medication profiles. The manager told us about a new development in how profiles and guidance are drawn up in relation to specific challenging behaviours, which is carried out by a designated manager for the county. This is in addition to the mandatory training staff members receive and helps to ensure that guidance in managing behaviour is more tailored to the individual concerned. How people like to make choices is clearly recorded in their care plans, including guidance on money management and any assistance required. Each person has a member of the staff team assigned as a key worker. Monthly meetings are held for people who use the service, providing an opportunity to participate and express their views about how the service is running. Discussion with three people who use the service confirmed that staff members respect their right to make decisions and give appropriate assistance. Two of these people indicated that they come and go as they please, but informed the staff of their movements. The other had free access to the community with staff support in line with their risk assessment. We saw that the service has developed a new format for risk assessment. The manager told us that she also has plans for improving person centred care plans for people who stay for longer periods. The service has been and is involved in the assessment process to identify future appropriate accommodation for these individuals. Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 & 17 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People using the service benefit through opportunities to take part in chosen activities, access community facilities, maintain relationships and participate in the planning of meals. Peoples’ rights and responsibilities are recognised in the daily routines of the home. EVIDENCE: Through looking at care plans and daily records and speaking to three people who use the service, we saw that there are opportunities for accessing local shops and facilities during the day and clubs and cinema in the evening. We saw evidence of individuals attending church, going to college and visiting charity shops and car boot sales in line with their recorded preferences. Some of the people who use the service attend day services and a local arts and drama centre. One of the people we spoke with is supported to maintain a Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 13 part-time job, enjoys cooking at Croft House and going out independently, including the use of the local buses. The service uses an annual survey, which asks people their views about meals and activities, among other things. As a result of this, we saw that the service has developed individual activity charts, which are also kept by the individuals in their rooms. This helps to ensure that planned and unplanned activities take place for people who come to stay. The manager told us how the service looks carefully at the compatibility of people coming into the service for respite. This can sometimes be a challenge when there are numbers of longer staying people in the service. The service also encourages input and feedback from people’s relatives and representatives, in order to provide a person centred service. One of the people we met had received a visit from a relative and friend and we had the opportunity to speak with them. They told us that the service at Croft House is “first class” and confirmed that staff members are available to provide support, while enabling people to maintain their independence. The person who uses the service said “I love it here. It’s like a hotel.” They also indicated that the service is flexible, telling us “if I’m out they put a meal up for me to have later.” We saw that dietary requirements are clearly recorded and people we spoke to confirmed that food preferences are respected. A member of staff told us how one person who uses the service now has an improved diet following a programme of support. People we spoke with told us “the meals are nice.” The service’s annual quality assurance assessment (AQAA) told us that the service is aware of the need to explore a more varied, diverse range of opportunities whether it be leisure or occupational for people who use the service to access. With regard to menu planning, as there is such a wide range of people accessing the house, with varying needs, the service is looking at developing a more accessible, pictorial format for choosing meals. This especially applies to foods of different cultures, which many people have not had the opportunity to explore. This development will include taster days and themed menus. The manager also told us about plans to convert a lounge on the first floor, which is not currently used much, into a ‘cinema’ and also plans for a sensory garden. The service has a pet rabbit called George, who visits the house from time to time. Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 & 20 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who use the service receive personal and healthcare support to meet their individual needs and are protected by the home’s medication policies and procedures. EVIDENCE: Care plans included sections relating to support with personal care, which gave details of how individuals’ prefer to be supported. The service has a system whereby care plans are updated each time a person comes to stay, so that any booked health care visits are not missed. Daily records showed that individuals were receiving continuing support to attend appointments, for example hearing and sight specialists. Staff we spoke with demonstrated their knowledge of individual’s personal support and health care needs, consistent with the care plans. The service assists people who stay longer at Croft House to be registered with a local doctor. The service provides equipment, such as a hoist and two specialised beds as well as regular staff training in moving and handling people. Our observations and discussions with three people who use Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 15 the service and two relatives confirmed that staff members support people well and respect their privacy and dignity. At the previous inspection we were informed that there were plans underway for all people who use the service to be able to keep their medication in their rooms, for which suitable storage facilities are provided. During this visit we saw that this is now the case and two of the people we met were managing their own medication, which had been risk assessed. The manager told us that under the local procedures, the service has to demonstrate reasons why any individual is not able to retain and administer their own medication. There is also suitable storage for medication that may be held on behalf of individuals, such as controlled drugs and a register is kept for this. Records showed that members of staff involved in administering medication had received training. Clear records are kept of medication coming into and leaving the service, along with records of what medication individuals receive during their stay. Prior to admission, a designated staff member telephones peoples’ relatives or representatives to ask if there have been any changes in relation to medication and this is recorded on the care plan. Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who use the service can be confident that any concerns they have will be taken seriously and acted upon. The home’s policies and procedures, backed up by regular staff training, protect people who live in the home from abuse. EVIDENCE: The service’s annual quality assurance assessment (AQAA) told us that people who use the service and their families have access to written information on the complaints procedure. The procedure can also be provided in formats appropriate to specific needs, such as visual impairment. All complaints are dealt with by the registered manager and will be addressed formally within 28 days if not sooner. There is an adult safeguarding procedure, shared within local authority services. All staff members are trained on the issues relating to safeguarding and are aware of the Whistle Blowing guidance, which protects staff members who report abusive practices within the organisation they work for. The registered manager has a local interest and involvement in safeguarding issues, which can then be transferred to the service in terms of expertise and practise. At the previous inspection we were informed that there were plans to provide the complaints procedure in picture format so as to be accessible to a wider range of people. During this visit we saw that this has been done and copies of this are available in the bedrooms at Croft House. The manager keeps a Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 17 record of all complaints and how they were responded to. The service had received one complaint, in 2007, which we saw had been responded to in line with the procedure. The manager confirmed there have been no complaints received by the service this year. We have also not received any concerns or complaints about the service in the time since the last inspection. People we spoke to who receive a service indicated they know who to speak to if they are not happy with the care and support they receive. The manager confirmed there have been no safeguarding issues at Croft House. We spoke with a member of staff who was clear about how to report any safeguarding matters and the limits of their own involvement. Mandatory staff training in responding to issues of suspected abuse is given during the induction and there is follow up training annually for all staff. All staff members take part in SCIP (Strategies for Crisis Intervention and Prevention) training. The home operates a robust staff recruitment procedure, which further demonstrates that people who use the service are protected. Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 & 30 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who use the service benefit from having a clean, pleasant and comfortable environment to live in, which meets their individual needs. EVIDENCE: The service’s annual quality assurance assessment (AQAA) told us that Croft House has been through an extensive period of redecoration and refurbishment within the last year. The service has also obtained two special ‘Profile’ beds, to assist in meeting the needs of people who have physical disabilities and mobility issues. The manager also told us that new garden furniture is on order. During our visit we saw the communal areas of the house and also three bedrooms. We saw that the house has been fully re-decorated and new good quality furniture has been provided. Since the last inspection, additional office space has been created upstairs, which provides a quiet area for administrative Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 19 work and staff supervisions. We saw the home has a maintenance system, including contacts, records and tracking. Those people who are longer-term residents had personalised their rooms with their belongings. Individuals we spoke to told us they liked their accommodation. Two people are sharing the first floor flat and one of them told us how much they enjoy this, saying “we both like the same TV programmes.” The relative and friend of one individual also commented on the pleasant surroundings. The AQAA also told us that Croft House has a unit laundry facility as well as individual domestic laundry facilities within the flats and upstairs. This enables people who use the service to develop their skills in the care of their own clothing. The service employs domestic support 5 mornings a week. This member of staff helps to encourage individuals to maintain an acceptable level of cleanliness throughout their personal space, as well as within the building as a whole. During our visit we observed a very good standard of cleanliness throughout the premises. Staff members receive training in infection control as part of their induction. Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 & 35 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who use the service are protected by the home’s recruitment procedures and are supported by well-motivated, trained and supervised staff. EVIDENCE: The previous inspection identified a requirement that records relating to staff recruitment must be held in the home with all the required information. The service’s annual quality assurance assessment (AQAA) told us that all staff members had undergone relevant recruitment checks. Also that there is induction, training and development programmes in line with the national minimum standards for the service. During this visit we looked at a sample of recruitment records in relation to three staff members, who had commenced or returned to work in recent months. These contained all the required information, such as dates of employment and completed job application forms, two written references and evidence of satisfactory Protection of Vulnerable Adults (POVA) and Criminal Records Bureau (CRB) checks. This demonstrates that people who use the service are being protected. The manager informed us that two more staff members are in the process of being Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 21 recruited to make sure the staffing levels meet the current level of people’s needs. The AQAA states that training needs for staff members are identified upon induction, and in addition to the mandatory training courses such as SCIP (Strategies for Crisis Intervention and Prevention), Food Hygiene, Moving and Handling, Adult safeguarding, First Aid and Fire Safety, specific unit and individual training needs are identified through supervision and personal development reviews. Croft House currently has 3 full time staff members, not including the manager, who have undertaken NVQ 3, and 2 staff who have just commenced the course. The manager told us that until recently there had been more NVQ qualified staff members, some of who have moved to other services. During our visit we looked at the staff training and development matrix, which showed a comprehensive programme of induction and training to equip staff to meet the needs of people who use the service. A member of staff we spoke with told us that they thought that the training is good, relevant to their work and is provided “pretty quick.” The records showed that staff members are booked onto training courses as soon as possible and there are regular training updates. In addition to the corporate induction, the service runs its own induction for new staff. This includes an introduction to people who use the service and related records, communication systems within the service, local orientation, training and development. The manager told us that for the first two weeks, new staff members only work on day shifts to allow them to get used to the way the service operates. The sample of personnel records we saw showed that formal staff supervision takes place within the service and a member of staff confirmed this. We also saw records of senior and support staff meetings, when matters relating to people who use the service, new referrals, supervision, staff and corporate issues are discussed as part of the agenda. Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 & 42 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home is well run and management practices promote the wellbeing and best interests of the people who use the service. EVIDENCE: We were assisted during our visit by the registered manager, who was responsive to people who use the service, visitors and staff and demonstrated a clear understanding of her role, the legal requirements of the job and continuous development of the service. The manager is in the process of completing the NVQ 4 registered managers award (RMA). A member of staff we spoke with confirmed that the manager is available regularly within the service for support. Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 23 A number of day-to-day management roles and responsibilities within the service are delegated to staff members, so that they have a shared sense of ownership. This also makes sure that the service continues to run smoothly in the manager’s absence. Staff members who assisted us during our visit were knowledgeable about the service and understanding of issues affecting people who use the service. The service’s annual quality assurance assessment (AQAA), which had been completed by the manager, provided us with a lot of detail and evidence of what the service does well and what plans are in place for further improvements. We saw a sample of the results of a service user survey questionnaire completed in January 2008, which indicated a high degree of satisfaction with the quality of service provided. The questionnaire was in a pictorial and user-friendly format. As mentioned in the section on Lifestyle, the manager had responded to questions raised in the survey about activities. There is a business plan for the service for 2007 – 08. Unannounced Regulation 26 inspections are conducted on a monthly basis. The most recent of these showed that action had been taken to make the furniture in the home more comfortable, once this had been identified as an issue. Also two fire doors were being fixed. This demonstrates effective monitoring of the service. We saw other evidence that demonstrates safe working practices are promoted and maintained within the service. The home has a fire risk assessment and regular checks are made of the fire warning system and equipment. There is a designated fire safety co-ordinator and records of fire training and evacuation drills are on file. The mobile hoist had been checked and serviced. The manager told us there is a centralised accident and incident reporting system, which monitors the rate and pattern of any occurrences. Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 24 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 3 2 3 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 25 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. 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. Refer to Standard Good Practice Recommendations Croft House DS0000033288.V367391.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000033288.V367391.R01.S.doc Version 5.2 Page 27 - 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!