Inspection on 21/09/06 for Croft Manor Residential Care Home

This inspection was carried out on 21st September 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 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 Manor Residential Care Home 17/09/08

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

CARE HOMES FOR OLDER PEOPLE Croft Manor Residential Care Home 28 Osborn Road Fareham Hampshire PO16 7DS Lead Inspector Peter J McNeillie Unannounced Inspection 21st September 2006 09:30 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 Manor Residential Care Home DS0000067743.V311056.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 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 Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Croft Manor Residential Care Home Address 28 Osborn Road Fareham Hampshire PO16 7DS 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) 01329 233593 01329 220844 Heathfield Care Homes Limited Mrs. Dawn McInnes Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (20), Old age, not falling within any other category (20) Croft Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Not applicable Brief Description of the Service: Croft Manor is a privately owned and run care home situated within easy walking distance of Fareham Town Centre, local shops and amenities. Public transport is easy to access as is the M27 motorway, which links the cities of Southampton and Portsmouth both within travelling distance of approximately 30 minutes. The home is able to accommodate up to 20 persons from of 65 years including those suffering from dementia or other mental health problems. Accommodation is available on the ground and first in 18 single and 2 twin rooms all with en-suite facilities. The home, which was re registered to new owners in June 2006, retained the previously registered manager and staff group. Croft Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection since the home was registered on 12/06/06. During the inspection, which took place between 9:15am and 2:30pm, the inspector spoke with a number of resident’s (individually and in groups), the registered manager and staff on duty. Evidence was also gathered from a tour of the building, reading records residents/staff, care plans, comments by management/staff records, reports to the Commission Of Social Care Inspection (C.S.C.I.) under regulation 26 and a pre inspection questionnaire provided by the homes Registered Manager. What the service does well: What has improved since the last inspection? Not applicable. Croft Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Croft Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 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 Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 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): 3 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home has a system of assessing and identifying residents needs which ensures residents safety and assessed needs can be met. EVIDENCE: Croft Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 9 A sample of four residents records were viewed, these confirmed persons were only admitted on a planned basis following a multi disciplinary assessment of need and risk by the manager (who visits the potential resident in their own home) of external health care professionals if appropriate. Potential residents are invited to visit and have a short stay prior to admission, which is reviewable after one month to ensure all parties are satisfied with the arrangements. Verbal confirmations by residents and signatures on records viewed confirmed residents or their representatives were consulted and contributed to the assessment process. Records also confirmed assessments of need and risk for all residents are reviewed on a regular basis and care plans adjusted if required. Respite care is not available in the home. Croft Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 10 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): 7,8,9 and 10. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The arrangements for planning care are clear ensuring that the health, personal care and medication needs of residents are met and their privacy and rights respected. Plans need to include a written confirmation that residents/residents representatives were consulted about and are aware of the contents of the plan. EVIDENCE: Croft Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 11 A sample of four residents records were viewed, four residents spoken with on a one to one basis and a number of others in groups. All of the residents spoken with expressed total satisfaction with the care they were receiving and the manner in which it was delivered. They also confirmed they were consulted about the contents of their individual care plan and the assessments on which the plan was based. All were aware they could view their plan at any time. Care plans which were reviewed monthly contained information on how identified needs including any special needs were to be met. Residents confirmed any personal care was given in private and staff always knocked and waited before entering their bedroom. The inspector observed this practice. Residents are able to make and receive telephone calls in private. A number of residents had made arrangements to have their own phone installed. Files seen and comments made by staff confirmed consultation with a range of external health care professionals such as doctors, district nurses, community psychiatric nurses, geriatricians, and continence advisors as required. Records viewed confirmed all resident’s drugs and medicines which are securely stored are administered and disposed of in accordance with the homes medication policy and procedure by trained staff (training records seen). No residents were self-medicating following a risk assessment. Staff confirmed residents or their representatives were free to choose their own GP (Currently approximately 22 doctors from at least 4 local practices visit) and the source of other personal services e.g. chiropodists, dentists optician etc. Assistance in accessing any service in the community was available. Any restriction on choice with regard to a GP was outside the control of the home. Croft Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 12 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): 12,13,14 and 15. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The social activities family contacts and the provision of varied and nutritious meals were well managed and reflected service users interests and choices. EVIDENCE: Croft Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 13 Residents confirmed they were very happy and contented about living in the home, comments such as “The best” ”lovely here” “hotel service” also stated they would recommend the home to anyone if asked. All were very complimentary about the homes staff and management. Residents confirmed they were able to exercise choice in respect of all aspects of their day-to-day lives bedtime’s mealtimes, visiting or receiving relatives/friends including attending in house activities, which included, craft and reminiscence therapy, bingo, P.A.T dogs, walks, flower arranging, and visiting special entertainers. Residents praised the quality, quantity, choice and presentation of food, which is provided . The inspector witnessed the preparation of the midday meal and would confirm the excellent manner in which the food was presented. A number of residents stated the food had improved considerably since the new owners took over. A menu based on resident’s likes and dislikes and nutritional needs was available as were choices to the main dish. At the time of the inspection no residents were on special diets.. Tea and coffee was available at all times. Croft Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home has clear policies and procedures in place which ensures residents are protected from abuse. The complaints procedure was satisfactory with evidence that residents feel their views will be acted upon. EVIDENCE: A policy/procedure that operates in tandem with the policy and procedure produced by Hampshire County Council designed to protect vulnerable residents from abuse was available as were records to confirmed all staff had received training . Staff spoken with confirmed they had received training in recognising abuse and demonstrated to the inspector they were aware of what to do should they witness or suspect the abuse of any resident. The complaints procedure, which was also included in the service users guide included information on how to contact The Commission for Social Care Inspection (C.S.C.I), was seen, as was record of complaints. Resident stated they felt comfortable in discussing any concerns they had with the homes management and confident any matters raised would be dealt with fairly and promptly but were very insistent in making it very clear to the inspector “They did not have concerns”. Croft Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 15 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): 19 and 26. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. A safe, well maintained, clean and suitably furnished home is provided for service users which meets their needs. EVIDENCE: A tour of the building indicated that it was fit for its stated purpose, accessible, safe, well maintained and meeting resident’s individual and collective needs. Furniture was comfortable and homely and in keeping with the décor. Residents commented how satisfied they were with the accommodation. Following specialist assessments, a number of communal and personal aids have been provided. These include handrails, ramps, bath hoists, raised toilets, and a passenger lift. The home was clean, hygienic and free from adverse odours. An infection control policy and procedure was in place. Croft Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 16 All residents were able to access the well-tended secure garden including those persons prone to wander and put themselves at risk. A maintenance programme is in place. Recent improvements included a new floor to an upstairs bathroom, redecorating a bedroom plus a new floor in the en-suite etc. Croft Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 17 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): 27 and 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Resident’s needs are met by sufficient numbers of well trained and supported staff who are recruited and selected using a procedure designed to protect all service users. EVIDENCE: The staff rota provided prior to the inspection as part of the pre inspection documentation, indicated that three staff plus the manager were available in the morning reducing to two in the evening prior to the night staff commencing work. Residents stated, ”We never have to wait. ” “When we want help it is always there”. The manager confirmed that staffing levels are closely monitored to reflect the assessed needs of residents and would be increased if the need arose This matter will be reviewed at a future visit to the home. To ensure residents safety, all staff are recruited and selected in accordance with a homes recruitment and selection policy and procedure which involves, the completion of an application form, an interview the signing of a rehabilitation of offenders declaration and satisfactory Criminal Bureau Records (C.R.B.), Protection of Vulnerable Adults (P.O.V.A), medical checks, reference checks, identity checks, and if appropriate work and resident permit checks, prior to the commencement of employment. Croft Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 18 On commencement of employment all staff are subject to in-house induction training following which they are expected to participate in National Vocational Qualification (N.V.Q.) training programme. Currently one manager and fourteen care staff 64.2 of who are qualified to N.V.Q. level two. In addition two members of staff hold a non-British nursing qualification Apart from the above all staff are involved in additional training covering the administration of medication, food hygiene, moving and handling, first aid health and safety, infection control and the protection of vulnerable adults, dementia care and any other subjects as determined and agreed during regular one to one supervision. Croft Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The management of the home ensures the health, safety and welfare of residents and staff are promoted and the home is run in the best interests of the residents whose views about living in the home are formally sought. EVIDENCE: The registered manage who has a considerable number of years experience in a senior capacity is a registered 1st level nurse, and has completed an N.V.Q qualification level 4 in management. There are clear lines of accountability within the home all staff when spoken to demonstrate they were fully aware of their responsibilities. The manager informed the inspector that the external management who visit daily were very supportive and receptive to ideas that improved efficiency and the quality of life for residents. Croft Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 20 The inspector viewed responses to a ‘Service User Satisfaction Questionnaires’, as a part of the home’s quality assurance programme, which confirmed satisfaction with the services offered. Residents spoken with also all commented on how nice the home was, and confirmed they were consulted regarding the services offered which included residents meetings. The inspector was also shown an action plan drawn up by the manager to address any points rose by the questionnaire. Currently the surveys do not include visiting professionals. The manager gave a verbal undertaking she would ensure this was done. This matter will be reviewed at a future visit. The home’s manager confirmed that monies were held on behalf of some residents. The inspector examined a sample of records and receipts, which reconciled with individually labelled monies held securely for safekeeping The inspector observed no immediate obvious hazards to health and safety during the inspection. Cleaning materials and chemicals were securely stored and staff had access to information requiring to be held under COSHH regulations. Protective clothing and gloves were available to staff for use when necessary. The home has a health and safety policy, a copy of which is given to new staff. Staff spoken with showed an awareness of the need to attend to health and safety matters or to report these to the manager for action. The home has a laundry procedure and the industrial washing machine is capable of disinfecting soiled items. A sample of policies and records relating to the servicing of equipment used within the home agreed with the information provided by the manager in the pre inspection report, this included the home’s fire and accident books. All records, which are easy to access, were securely stored Croft Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 21 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Croft Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 22 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 Manor Residential Care Home DS0000067743.V311056.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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