Inspection on 22/09/05 for Croft (The)

This inspection was carried out on 22nd September 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 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 (The) 10/10/08

Croft (The) 15/10/07

Croft (The) 20/12/06

Croft (The) 27/02/06

Croft (The) 28/09/04

Croft (The) 26/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Croft Walsingham Way Eye, Peterborough PE6 7XB Lead Inspector Alison Hilton Unannounced Inspection 22nd September 2005 08:10 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 The Croft DS0000035244.V250796.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Croft DS0000035244.V250796.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Croft Address Walsingham Way Eye, Peterborough PE6 7XB 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) 01733 222448 01733 223895 Peterborough City Council Jill Frances Waywell Care Home 39 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (6), Old age, not falling within any other of places category (39), Physical disability (3) The Croft DS0000035244.V250796.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users admitted under the categories DE and PD must be over the age of 60 years. 28th September 2004 Date of last inspection Brief Description of the Service: The Croft is owned by Peterborough City Council and is situated in the village of Eye, approximately six miles from Peterborough City centre. The home was purpose built in the 1960s and now accommodates up to 39 elderly service users. The accommodation is on two floors and comprises 39 single bedrooms. All bedrooms have washbasins. There are 15 WCs, 4 bathrooms, 1 shower room, 4 sitting rooms (three with dining areas) and a visitors’ room. There is a lift that operates between the two floors. The home is set in its own grounds, which are secure, and wheelchair accessible. An application to vary the registration to include 6 beds for older people diagnosed with dementia and 3 beds for adults between the ages of 60 and 65 years was agreed in September 2005. The Croft DS0000035244.V250796.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on Thursday 22nd September 2005 between 08:10 and 16:00 hours. Two deputy managers, staff, residents and visitors were spoken to. Staff and resident files were inspected and other logs and records seen. There were 38 residents in the home and one in hospital at the time of the inspection. The inspection continued on Wednesday 28th September when the manager was available to ensure the information in staff files was or was not on site. What the service does well: What has improved since the last inspection? What they could do better: 1. Care plans still require some work to ensure there is enough detail for staff to be able to deal with the needs of individual residents. The Croft DS0000035244.V250796.R01.S.doc Version 5.0 Page 6 2. On speaking with an assistant manager it was evident that staff they should supervise were not receiving it on a regular basis. 3. Files for staff should contain details of Criminal Record Bureau checks and references. 4. Staff who administer medication must be competent to do so. 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 Croft DS0000035244.V250796.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Croft DS0000035244.V250796.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,5,6 The home cannot ensure that the needs of the resident can be met as a proper pre-admission assessment is not always completed. EVIDENCE: The home does not provide intermediate care. There was evidence on the files of residents that they received a copy of the contract for the home. Talking to residents they said that they or their family members had visited the home prior to moving in. A family member who was visiting at the time of the inspection confirmed that they had been to the home before their relative became a resident. Individual files are kept for each resident and on some of the files seen during the inspection there were assessments prior to the resident coming to live at the home. Some pre-admission assessments contained more The Croft DS0000035244.V250796.R01.S.doc Version 5.0 Page 9 detail than others. The file of one resident did not contain a pre-admission assessment although they had been to the home for regular respite. The Croft DS0000035244.V250796.R01.S.doc Version 5.0 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): 7,8,9,10 The home is unable to demonstrate how residents needs will be met, as care plans, which are supposed to provide the basis of the health, personal and care needs of residents have not been completed adequately. Although the home does usually complete risk assessments for individual residents, there were no risk assessments on one file, and a lack of specialist risk assessments on others. This has the potential to place the residents and staff at risk. The lack of staff training in the administration of medication compromises the safety of residents. Staff demonstrated positive and caring actions when dealing with residents, respecting their privacy and treating them with respect. EVIDENCE: Individual plans of care were seen on residents’ files although they still do not ensure that all aspects of health, personal and social care needs are identified. The Croft DS0000035244.V250796.R01.S.doc Version 5.0 Page 11 One of those completed was well done but some were not dated, the resident or their representative did not sign others and this would have provided evidence of their inclusion in the process. One resident was on respite care and the information on file was from a previous respite stay in March 2005. There were no indications as to whether this information remained current or what changes had occurred in 6 months. It was therefore unclear what care staff were working from in relation to the care needs and risks for this resident. Other forms that the home completes for each resident such as background information forms need to have all areas filled in or if not applicable then that should be stated. An example of this was in relation about whether money had been handed in at the time of admission. The home also has a ‘This is your Life’ form for background information on each resident but this had not been completed for a resident who had been in the home for over two months. For one resident there was no evidence of any risk assessments being completed that would ensure appropriate care and any necessary preventative measures to be taken by staff. Another resident who had fragile skin had not had a risk assessment in relation to tissue viability. Where residents needed things such as bed rails there should be evidence on the file of an assessment to demonstrate the need and an agreement by the resident or their family. If there is a dispute about the need then this should also be recorded. Staff were seen knocking on residents doors before entering and where one resident required hoisting each element was explained to him before it was done, this meant he was always aware of what was happening. During the inspection there were visits from a district nurse and two GP’s. There were entries on residents’ notes in relation to visits from health professionals. Visitors spoken to said that the home called the doctor or nurse when necessary. All staff who administer medication must be competent to do so. It was not clear to the inspector why assistant managers were the main staff who administered medication, or why they were completing care plans and risk assessments and not the care staff who worked with residents as key workers. Although the inspector was informed that key workers and residents were involved in care plans and reviews there was little evidence of this on file. The managers’ role would be to ensure that care plans, risk assessments and reviews were adequately completed when having supervision for example. The Croft DS0000035244.V250796.R01.S.doc Version 5.0 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): 12,13,14,15 The home provides sufficient variety of activities to ensure all residents have the opportunity to participate. Meals are nutritious, balanced and varied and provided in pleasant surroundings. EVIDENCE: A number of residents who commented on the food said they enjoyed it and were offered a choice. Menus were found to be balanced and provided a variety of hot and cold options. Most main meals were served in the dining rooms and meal times were found to be reasonably flexible. There were details of activities posted near the sitting/dining rooms and included things like hangman musicals, exercise to music and word search. Residents and visitors told the inspector that there are often trips out and they recently went to the coast and have been to garden centres. One visitor said, “They do lots of activities. Dad has recently been to Skegness and enjoys trips out.” In discussion with the manger it was suggested that the home keep a book detailing activities and who attended. Although these details are kept on individual resident files this would ensure staff could see at a glance who had not been involved in anything and they could then ask if they wished to or The Croft DS0000035244.V250796.R01.S.doc Version 5.0 Page 13 what activities they might enjoy. This would also include 1-1 time spent with residents. In the minutes of the residents meeting held on 1st September 2005 there were discussions about activities such as crafts (card making), trips to stately homes or into town, sherry evenings with snacks and a fish and chip evening. The Croft DS0000035244.V250796.R01.S.doc Version 5.0 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): 16,18 The vulnerable adult procedure ensures that the people living at the Croft are protected from abuse. EVIDENCE: Speaking to residents and visitors it was apparent that they were clear who they would talk to if they had a complaint, and although aware in many cases of a complaints procedure would not follow it and would just have “a chat with the staff” or “talk to the manager”. The Croft continues to have the relevant inter-agency policies and procedures in relation to the protection of vulnerable adults. The home is currently in contact with the adult protection team in relation to an issue in the home between residents. The matter is being dealt with appropriately and all parties are being kept informed. The Croft DS0000035244.V250796.R01.S.doc Version 5.0 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): 19,20,23,24,25,26 There are no specific improvements to be made as the home provides safe and comfortable surroundings. EVIDENCE: The home is well maintained. There were some cigarette burns on the carpet in the smoking lounge. There are indoor lounges, a smoking lounge and other areas where residents can sit quietly if they wish. The residents said that their bedrooms had personal possessions such as ‘photos, pictures, TV’s and small items of furniture in them. When the inspector arrived at the home there were some unpleasant odours but these had been dealt with later in the morning. The home was having new washing machines installed that day and there were problems in where the dirty laundry could be placed and where it was going to be washed. The Croft DS0000035244.V250796.R01.S.doc Version 5.0 Page 16 Gloves and aprons are provided to prevent the spread of infection. The toilets all have appropriate washing facilities with soap dispensers and paper towels. The Croft DS0000035244.V250796.R01.S.doc Version 5.0 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): 27,29,30 The procedures for the recruitment of staff do not offer protection to the residents in the home. The homes training programme does not ensure all staff are trained and competent to do their job. EVIDENCE: The Croft has a manager and three assistant managers. The assistant managers are responsible for the four units in the home, two have one unit and one has two units. The home still uses agency staff but on talking to the homes care staff there are regular agency staff who are used, this allows for some continuity of care. The Croft does not allow the home to be solely staffed by agency carers at any time. If there are to be only agency staff on duty at night then an assistant manager will be on sleeping in duty in the home. The staff rota was seen and it was noted that there was an extra staff member on duty to ensure the safety of residents. On the day of inspection there were 7 staff on during the morning (one was agency) and 6 in the afternoon (3 were agency). Staff records were seen for three members of staff. One file could not be found during the first visit but was available at the second. All necessary The Croft DS0000035244.V250796.R01.S.doc Version 5.0 Page 18 information was on this file. One file had all the necessary papers during the first visit. The third file did not have a CRB check on file. On speaking to the manager it was evident that the papers go to a different office and had not been forwarded to the home yet, although she had been given the go ahead to start the person. The manager said she would ensure the check was completed and a copy placed on file as soon as possible. The assistant manager on duty at the time of the inspection said that details of agency staff and what training they had completed was available. Residents said that staff were “very kind and helpful”, “extremely caring”, “noone harasses you”, “staff are nice and do anything for you”, “they’re all very good”, a visitor said, “the care is wonderful”. Staff spoken to said they were busy but not understaffed. There is a significant amount of staff sickness at the home, some of which is long term. Staff said they had received recent training in moving and handling, food hygiene, fire safety, 3 day challenging behaviour, vulnerable adults (protection from abuse), and dementia. Some domestic staff said they had not had training in protection of vulnerable adults. Staff administering medication must be competent and had the competency assessed. The Croft DS0000035244.V250796.R01.S.doc Version 5.0 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): 31,35,36,38 Until the new system of holding residents monies is in place their financial interests are not safeguarded. EVIDENCE: The manager has completed and received the certificate for the Registered Managers Award and is intending to start the NVQ Level 4 in Management. Staff, residents and visitors said that the senior staff were approachable and it would be them they went to if they had any concerns or complaints. The home has regular meetings with residents, the last held on 1st September 2005. Menus were discussed as well as outings, entertainment, happiness with own rooms and communal rooms and timing of hairdressing appointments. The Croft DS0000035244.V250796.R01.S.doc Version 5.0 Page 20 The home has recently appointed a new administrator and she said that there was a new system being introduced where each resident had their own account and not as it currently is with the home having the account with all residents money held there. Families hold the accounts for 10 residents. A cashbook is completed for all transactions. Receipts are kept by the home. The fire book was seen and all checks are being completed as required. The Croft DS0000035244.V250796.R01.S.doc Version 5.0 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 3 2 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 2 3 X 3 The Croft DS0000035244.V250796.R01.S.doc Version 5.0 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. 1 Standard OP3 Regulation 14 Requirement The registered person shall not provide accommodation to a resident unless a suitably qualified or trained person has assessed the needs of the resident. The registered person shall after consultation with the resident or their representative, prepare a written plan as to how the residents needs will be met. Risk assessments must also be completed. The registered person must ensure that anyone employed at the home has a current Criminal Record Bureau Check completed. The registered person shall not pay money belonging to a resident into a bank account unless it is in the name of the resident. Timescale for action 01/10/05 2 OP7 13 & 15 31/10/05 3 OP29 19 28/09/05 4 OP35 20 31/10/05 The Croft DS0000035244.V250796.R01.S.doc Version 5.0 Page 23 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 OP30 Good Practice Recommendations Staff administering medication should be competent and have had that competency assessed. The Croft DS0000035244.V250796.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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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