Inspection on 28/03/08 for Croft, The

This inspection was carried out on 28th March 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, The 09/03/07

Croft, The 03/11/05

Croft, The 11/05/05

Croft, The 13/10/04

Croft, The 08/06/04

Similar services:

21 High Street

Vale House

Chestnut Walk

Dunwood Manor Nursing Home

The Old Vicarage

Excelsior

Cherwood House Care Centre

Durban House Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Croft, The Hooke Hill Freshwater Isle Of Wight PO40 9BG Lead Inspector Janet Ktomi Unannounced Inspection 09:30 28 March 2008 th 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, The DS0000012480.V361381.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, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Croft, The Address Hooke Hill Freshwater Isle Of Wight PO40 9BG 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) 01983 752422 01983 752422 carolione.metcalf@virgin.net Mrs Patricia Anne Foster Mrs Caroline Joy Metcalf Care Home 16 Category(ies) of Dementia - over 65 years of age (12), Learning registration, with number disability over 65 years of age (2), Mental of places disorder, excluding learning disability or dementia (2) Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one named person, under the age of 65 years, in the (DE) category 9th March 2007 Date of last inspection Brief Description of the Service: The Croft is an extended detached house in a residential area of Freshwater, close to all amenities. It is registered as a care home for a total of 16 residents, 14 over 65 years of age and 2 under 65 years. The home specialises in caring for people with dementia and/or mental health problems. The home is on two levels and as there is no passenger lift the residents in the four upstairs bedrooms need to be mobile. With the exception of one twin room all bedrooms are for single occupancy, none of the bedrooms are en-suite. The home is owned by Mrs P Foster and managed by the registered manager Mrs Caroline Metcalf. Weekly fees range from £361.97 to £490.00 dependant on assessed needs. Croft, The DS0000012480.V361381.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 star. This means the people who use this service experience good quality outcomes. This report contains information gained prior to and during an unannounced visit to the home undertaken on the 28th March 2008. All core standards and a number of additional standards were assessed. The visit to the home was undertaken by one inspector and lasted approximately six hours commencing at 09.45 am and being completed at 3.45 p.m. The inspector was able to spend time with the registered manager and staff on duty. The inspector was provided with free access to all areas of the home, documentation requested, visitors and people who live at the home. During the inspection visit the manager was completing the homes Annual Quality Assurance Questionnaire (AQAA), this was received at the Commission following the inspection and information from it is included in this report. Information was also gained from the home’s file containing notifications of incidents in the home. During the visit to the home the inspector was able to meet with and talk to many of the people who live at the home and a visitor. The inspector was able to talk to many of the homes staff as they were at the home during the afternoon of the inspection for manual handling training update. What the service does well: The home has a comprehensive pre-admission procedure, which ensures that people are able to make an informed decision as to whether to live at the home and that the home can meet their needs. All evidence indicates that the home ensures that people’s health and care needs are fully met. People living at the home stated the food is always/usually good with choice available. The home employs appropriate numbers of care staff that ensure that people’s needs are met. Staff receive the necessary training. The home has a high Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 6 number of staff with an NVQ level 2 in care. The home has contracted with an external training organisation who have undertaken a training audit of the home and provided a training plan as well as identifying additional funding that may be available to support training in the home. What has improved since the last inspection? Following the previous inspection nine requirements and one recommendation was made. The home has addressed all these issues. The manager was required to review all risk assessments to ensure that they were still relevant to the person. Risk assessments viewed during this inspection visit had been reviewed and appeared appropriate to the person concerned. The home was required to ensure that manual handling guidelines were adhered to at all times. Staff were attending a manual handling update session on the day of the unannounced inspection visit, care plans contained manual handling risk assessments and management plans. Staff were observed using correct manual handling techniques throughout the inspection. The home was required to ensure that it had a recent photograph of everyone who lived at the home, photographs were present in all care plans. Following the previous inspection the manager was required to ensure that medication administration records were fully maintained and that as required medication guidelines were in place. These records were fully maintained at this inspection visit. There were no incidents when people were not treated with dignity and respect at this inspection visit. The home has replaced all damaged and old furniture with new dining room tables and chairs as well as some new bedroom furniture being provided. All bedroom radiators are now covered. The home was found to be clean and no offensive odours present. The home now has a cleaning schedule with care staff identified on a daily basis as to who is responsible for which areas of the cleaning. All the necessary checks on new care staff are completed before they commence working at the home. The home has two new conservatories, one to be a sensory/relaxation room and the other to be a larger office/meeting room. The home has also purchased new industrial standard washing and drying machines. Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 8 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, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 5 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. All people are assessed prior to moving into the home to determine that their individual needs can be fully met. People, or their representatives, are able to visit the home prior to admission to assess the quality, facilities and suitability of the home. Standard 6 is not applicable, as the home does not provide intermediate care. EVIDENCE: The registered manager explained the homes admission procedure and two pre-admission assessments were viewed, both for people admitted shortly before the inspection visit. The inspector was able to speak with a person recently admitted to the home whose assessment had been viewed and discussed admissions with care staff. The registered manager stated that she is Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 10 in the process of reformatting the homes admission forms to make them more person centred. If an initial enquiry from either social services or from a person or their family indicates that the home would be able to meet the persons needs the manager will arrange to visit the person, either at their home or in hospital. A comprehensive pre-admission assessment is completed including where possible members of the persons family and professionals involved in their care. The person is provided with written information about the home and where practicable is invited to visit the home before making the decision as to whether to move in on a four week trial basis. When the person is unable to visit the home a relative is invited to view the available room and facilities at the home. The home has an assessment tool that covers all the relevant areas necessary for the home to decide if it is able to meet a prospective persons needs. The manager was clear about the level of care needs the home can accommodate. The home provides respite care if a bed is available and the manager stated that the above procedures are followed. The records for one person who was first admitted for respite before deciding to remain as a permanent resident were viewed and confirmed that the above admission procedures had occurred. Discussions with care staff on duty and those visiting the home for training confirmed that they felt they had enough information about new people admitted to the home. Residents at The Croft tend to be long term. The home does not provide dedicated accommodation for short-term, intermediate care or specialised facilities for rehabilitation. However, as mentioned respite care is provided, if there is a room available. There was no evidence that this arrangement had any negative impact on the existing residents. Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health, personal and social care needs are set out in an individual plan of care. Medication is appropriately stored and records fully maintained. People are treated with respect and their dignity maintained. EVIDENCE: Four care plans were viewed two for people recently admitted to the home and the others for people who had been living at the home for a longer time. The inspector discussed with staff, a visitor and people who live at the home how care needs were met. The inspector telephoned a health professional who regularly visits the home. Care plans contained all the necessary information for staff to ensure that all aspects of health, personal and social care needs could be individually met. People have a detailed plan of care that related to the persons assessment. Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 12 The care plans are person centred and written in plain language providing detailed information as to how needs should be met. Plans are generally reviewed on a monthly basis although it was noted that some monthly reviews had been missed. Following the previous inspection the home was required to ensure that they had a photograph of all people who live at the home. Photographs were seen in all care plans. Care plans contained relevant risk assessments and management plans including nutrition, falls and any individual risks such as resulting from age related memory loss. Care plans also contained guidance for staff in how inappropriate behaviours should be managed by care staff. Following the previous inspection a requirement was made that the manager must review all risk assessments and update these to ensure they are still relevant to the service user. One care plan viewed had evidence that the risk assessments and management plans had been updated to ensure his and other peoples safety. Risk assessments in other care plans viewed appeared appropriate to the persons needs. The inspector was able to talk with four people who live at the home who stated that they always received the care and support (including medical care) they need. A relative met during the visit to the service confirmed that they felt that the needs of their relative living at the home were met. During a telephone discussion with a health professional who visits the home no concerns regarding peoples healthcare needs were raised. Following the previous inspection the home was required to ensure that manual handling guidelines are followed at all times. On the day of the unannounced inspection care staff off duty were at the home for a manual handling update. The inspector was able to observe manual handling procedures during the inspection visit and these were appropriate. Care plans contained individual manual handling assessments and guidelines. A visitor and people who live at the home stated that they felt that staff always treated them with dignity and respect. Observations of staff interactions indicated that people are treated with respect and their right to dignity maintained. All people confirmed that staff listen and act on what they say. The home provides mainly single bedrooms with the one twin room containing screens to ensure privacy during personal care tasks. Care staff confirmed that they had sufficient time to meet people’s needs and discussions indicated that they had a good understanding of individual peoples needs and how these should be met. Care staff have received training to meet the specific needs of people with further training arranged to ensure staff are able to support a person with diabetes. At the time of the inspection visit nobody was self administering his or her medication. The manager stated during the inspection and on the homes AQAA that staff, including herself, have undertaken external medications training in Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 13 December 2007. Medication is stored in the homes office in a locked medications trolley, which is secured to the wall when not in use. With the exception of liquids the local pharmacist dispenses most medication into weekly blister packs. The home uses medication administration record sheets supplied by the pharmacist that are pre-printed. These were viewed and found to be fully completed. Following the previous inspection the home was required to ensure that guidelines for as required medication are in place. Guidelines for as required medication were also seen in care plans. Discussions with the homes manager indicated that she is aware of the storage requirements for controlled medications and the home has the necessary storage and recording procedures in place. Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The routines for daily living and activities made available are flexible and varied to suit people’s individual needs. Family and friends are able to visit. People receive a balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: The inspector spent time talking with people in the homes lounge, met people who had chosen to remain in their bedrooms, observed part of the lunchtime meal and met with a relative. The routines for daily living and activities made available are flexible and varied to suit people’s individual needs. Residents and relatives confirmed to the inspector that they are able to choose where in the home they spend their day, many were seen to spend time in the homes lounge with others remaining in their bedrooms. Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 15 Care plans contained individual information such as times people like to get up. Many of the people living at the Croft have age related memory loss and care plans contained life history information and recorded peoples likes and dislikes. People confirmed to the inspector that they are given choice over their meals. Bedrooms seen contained personal items brought into the home. Care plans and assessments include information about leisure activities, hobbies/interests, catering and religious needs. People stated that they are able to get up and go to bed at times of their choosing. The manager explained that due to people’s individual needs most activities are 1-1. The manager informed the inspector that she has obtained funding for a course on activities focusing on dementia and Person Centred activities. The manager showed the inspector an occupational profiling book for use with people with dementia and age related memory loss to establish an individual activities programme relevant to the person’s interests. The home has a visiting musician on alternative weeks and on two days every week there is now three hours additional staff time dedicated to activities. Since the previous inspection the home has added two conservatories (almost completed), one of which is to become a sensory/relaxation room. The sensory/relaxation equipment was seen during the inspection visit. The home has a car suitable for transporting people in wheelchairs with one person seen going out for a drive and coffee during the inspection visit. Care staff stated that they have time to take people out when the manager is at the home as this still leaves sufficient staff to meet other people’s needs. One person living at the home has additional funding provided by social services for activities on a 1-1 basis. The inspector spoke with the person who confirmed that he is able to decide what he does and where he goes with his 1-1 time. Records of activities undertaken are kept by the home. Information about religious needs is included in care plans and the manager stated that she has contact details and would arrange visits from appropriate ministers/clergy if this were requested/identified as a need. The inspector was able to meet one visitor who stated that she was able to visit at any time and kept informed about issues affecting her relative. The home does not have a private room for visitors however the additional space provided by the two new conservatories does mean that increased privacy for meetings and visits would now be possible. The home has a dining area adjacent to the lounge. Most people were seen to have chosen to have their lunchtime meal at the dining tables however others stated that they preferred to have their meals in their bedrooms and this was accommodated. People stated that the food is always/usually good and choice provided. The inspector was present for the main lunchtime meal. People stated it tasted good. Drinks and snacks are also available throughout the day Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 16 with people confirming this as well as the inspector observing people being given morning and afternoon hot drinks and biscuits. The need for special diets or supplements is recorded pre-admission. The pre-admission form included information about people’s food likes and dislikes. One person is a vegetarian and discussions with the person and the cook indicated that she is provided with vegetarian food. The person was overheard thanking the cook for her lunch and stated that it had been very nice. The cook was aware of the dietary needs of people with diabetes. The inspector observed that several people were provided with their food in a liquidised format. All parts of the first course of the meal (fish, potato and vegetables) had been liquidised together producing a visually unappetising mixture. This was discussed with the manager following the inspection who stated that food would be prepared such that individual tastes could be distinguished. The home has a large, well-equipped kitchen. The provider stated that the home had recently been inspected by environmental health and awarded five stars (the maximum) for food hygiene. Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. People are protected from abuse. EVIDENCE: The home has a clear complaints policy and procedure and a copy is in the statement of purpose/service users guide, available in the hallway and provided to all prospective people and their relatives during the assessment procedure. The relative, the inspector met, stated that she was aware of how to complain and felt she would do so if she had any concerns. Discussions with staff confirmed they were aware of what to do if a person complained or raised an issue. The manager identified in the homes AQAA that the home had received no complaints in the past year. Discussions with visitors and residents during the inspectors visit indicated that people feel able to make their views and opinions known and are not afraid to raise issues with the homes staff or management. The home has a policy and procedure relating to safeguarding adults and ensuring that people are not at risk of abuse. Care staff have had safeguarding adults training as part of their induction and as specific update training as seen in the homes training matrix and individual training records and confirmed by Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 18 staff. Discussions with care staff indicated they had a good understanding of adult protection and what they should do if they suspected abuse may have occurred. Care plans were seen to contain guidance for staff as to how to support people who may present specific inappropriate behaviours. Care staff have undertaken training in Dementia and challenging behaviour with the manager stated that training on the new Mental Capacity Act is planned for the future. The homes policies and procedures in respect of people’s personal finances and recruitment should ensure that people will not be financially abused. Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a clean, safe, well-maintained home that meets their individual and collective needs. EVIDENCE: The croft is an extended older property located in a residential area close to the shops and other facilities in Freshwater. The Croft is domestic in style and provides comfortable and homely accommodation. There is limited off road parking to the front of the home with additional parking available in the road outside the home. The home has a large rear garden, mainly laid to lawn with a patio area to the side of the home. Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 20 Following the previous inspection requirements were made in respect of the homes environment and equipment. These have all been met. Since the previous inspection the home has added two conservatories to the front and side of the home. One is to provide improved office space for the manager and is large enough to double as a meeting room. The other new conservatory is to be used as a relaxation/sensory room. The conservatories were nearing completion at the time of the unannounced inspection with the inspector seeing the equipment for the sensory/relaxation room and new office furniture stored in one conservatory. The homes current office will then become a treatment/care staff room. Also since the previous inspection the home has purchased new tables and chairs for the dining area with new curtains in a number of bedrooms and a new divan bed base. The manager stated that there are plans to provide new lounge furniture. The home has a new washing machine and tumble dryer, of industrial design and capable of washing to disinfection standards. The tour of the building showed the home to be clean and tidy throughout and there were no unpleasant odours. At the time of the visit the home was comfortably warm throughout. The visitor and people who live at the home confirmed that the home is always warm and clean. The home does not employ a cleaner with care staff being designated various cleaning tasks. Care staff stated that they had sufficient time for care and domestic work. The home has mainly single and one twin bedroom. The inspector viewed a number of bedrooms. These vary in size, none have ensuite facilities, however bathroom and WC’s are located around the home and convenient to the communal areas and bedrooms. People able to respond stated they were happy with their bedrooms and these were seen to contain personal items. People confirmed that they could lock their bedroom doors and had a lockable facility within their rooms for valuables. The home has communal space with a range of seating suitable for everyone who lives at the home. The home has the necessary moving and handling equipment and the baths are fitted with hoists. Grab rails are provided around the home. Four bedrooms are upstairs and people admitted to these rooms must be able to manage the stairs, as the home does not have a lift. The home has purchased a portable stair lift should there be a need in an emergency. The manager confirmed that all radiators are covered and upstairs windows have opening restrictors for safety. The homes laundry was visited and is appropriate and fit for purpose with new machines capable of washing to disinfection standards. Members of staff spoken with confirmed they had received infection control training and had access to all the necessary equipment to prevent any risk of cross infection such as disposable gloves and aprons, supplies of which were seen during the visit to the home. Substances hazardous to health (COSHH) were stored securely. Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 21 Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home employs appropriate numbers of care staff that ensure that the needs of people living at the home are met. Staff receive the necessary training and a high number have a recognised qualification in care. EVIDENCE: All comments from people who live at the home, visitors and professionals were positive about care staff. A person who lives at the home stated ‘I am very happy and very well looked after’, ‘friendly caring staff at all times’, ‘everyone is very kind’, and ‘everyone is very nice’. Duty rotas were seen during the visit to the home. Duty rotas stated that three care staff are provided throughout the day and two care at night (one awake and one sleepin). The home also employs a cook and has maintenance staff available. In addition to care staff the manager is present weekdays and care staff stated she often also comes in at weekends. As previously stated one person is funded for 1-1 time and this is provided in addition to the care staff stated above. During the inspectors visit staff on duty corresponded to those on the duty rota. Care staff stated that they generally have sufficient time to Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 23 meet people’s needs and throughout the inspection care staff appeared to have time to meet people’s needs. The manager provided training and qualification information during the inspection and on the AQAA. The home has a high number of care staff with at least NVQ level 2 in care. With twelve of the seventeen care staff having a qualification (some at level 3). Of the remaining five care staff, two are due to commence their NVQ. The inspector spoke with care staff who confirmed that they had either got, were to undertake their NVQ. During the previous year the home has contracted with an external training provider who has undertaken a training/skills audit of the home as a whole and individually for each staff member. The results of this were shown to the inspector. A training plan has been produced to ensure that all staff have undertaken all the necessary training. This was viewed during the inspection visit. The manager is a train the trainer and a manual handling update session took place on the afternoon of the unannounced inspection with many staff off duty coming in for the training. Care staff stated that they felt they had the necessary skills to meet people’s needs and were not expected to undertake activities for which they had not been trained. The recruitment records for the three people recruited since the previous inspection was viewed. These contained all the required information and confirmed that all staff are fully checked including references, CRB and POVA checks prior to commencing employment at the home. The manager explained the homes induction procedure that includes the Skills for Care induction. Induction workbooks were seen along with certificates for courses staff had attended. New care staff confirmed that the above recruitment procedures had been undertaken. Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager has the necessary skills and experience to ensure that the home is appropriately managed and run in the best interests of the people who live there. People’s financial interests are safeguarded. Staff are supervised. Records are well maintained. The health, safety and welfare of people and staff are promoted. EVIDENCE: The manager has NVQ level 4 in care and the Registered Managers Award and has managed the home for over nine years. The manager also confirmed that she has undertaken all mandatory and specific training with care staff. Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 25 Throughout the inspection visit the manager demonstrate knowledge of the people who live at the home and the mechanisms by which support can be obtained when necessary. The manager works full time including some weekends. Care staff, people who live at the home and visitors were clear that they felt able to discuss any issues/concerns with the manager. The manager confirmed that she has access to the necessary budgets and is able to make decisions about spending in the home. Following the previous inspection nine requirements and one recommendation were made. These have all been met. The provider lives near the home and undertakes visit to the home providing monthly reports for the manager. These were seen during the inspectors visit. Due to the needs of people living at the home resident meetings are not undertaken. Since the previous inspection the manager has commenced some formal quality assurance work with monthly audits seen. The home has attained the investors in people award. The manager was completing the AQAA during the unannounced inspection visit. This was received at the commission within the required timescales. The AQAA contained relevant information. The manager is the appointee for one person who lives at the home and will hold small amounts of money for some people (this is used for small personal expenses such as hairdressing and newspapers), and invoices some other people for additional fees at the end of each month. The systems in place and records seen re people’s personal money are robust and well maintained. All staff have formal recorded supervision approximately every two months. Care staff confirmed during discussion that they are appropriately supported and supervised with an on call system in place when the manager is not at the home. Various records were viewed during the inspectors visit. All records were appropriately stored with access only available to people who should have access. Records were seen to be well maintained. During the inspectors visit there were no concerns in respect of health and safety identified. The home is generally well maintained and clean, with staff having relevant training to meet people’s needs. The home undertakes weekly checks of the fire detection equipment with all records regarding fire now in place as required following the previous inspection. The maintenance person undertakes Portable Electrical Appliance Tests (PAT) and the electrical wiring and gas certificates were seen. The local environmental health department has awarded the home five stars (the maximum) for food hygiene. Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 26 Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 27 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 3 3 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 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Croft, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? no 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, The DS0000012480.V361381.R01.S.doc Version 5.2 Page 29 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. 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